Your patient is breathing shallowly and seems irritable and restless. A nursing action that might help is to have him:
take a good nap
turn, cough and deep breathe
submit to a back rub
take some pain medication
The Correct Answer is C
A. Take a good nap: While rest is important, shallow breathing and irritability may indicate inadequate ventilation, which won't improve solely with sleep.
B. Turn, cough, and deep breathe: This helps open the airways, promotes alveolar expansion, and clears secretions, which may improve oxygenation and reduce restlessness.
C. Submit to a back rub: Although comforting, it does not directly address shallow breathing or improve oxygenation.
D. Take some pain medication: Pain control can be essential, but this action is premature without assessing whether pain is the cause of shallow breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Loop the client's tubes carefully to prevent kinking: Tubes should not be unnecessarily looped, as this may cause obstruction or tension.
B. Clamp the tube when the client is ambulating: Clamping increases the risk of tension pneumothorax and should be avoided unless prescribed for specific procedures.
C. Place the client flat to avoid leaks in the tubing: This position may compromise lung expansion; semi-Fowler’s or Fowler’s position is preferred.
D. Keep the collection device below the client’s chest level: This position uses gravity to prevent backflow of fluid or air into the pleural space.
Correct Answer is C
Explanation
A. Bradypnea: Hypoxia typically leads to tachypnea as the body attempts to increase oxygen intake.
B. Pallor: While it can be a sign of poor perfusion, cyanosis is more closely associated with hypoxia.
C. Cyanosis: A late sign of severe hypoxia, indicating a lack of oxygen in the tissues.
D. Bradycardia: Hypoxia usually stimulates tachycardia as the body tries to compensate.
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