The nurse is reviewing a newly admitted patient's electronic health record, which notes a history of orthopnea? What nursing action is most clearly indicated?
A) Teach the patient deep breathing and coughing exercises.
B) Administer supplemental oxygen at all times.
C) Limit the patient's activity level.
D) Avoid positioning the patient supine.
Ans: D
Feedback:
Orthopnea is defined as difficulty breathing while lying flat. This is a possible complication of HF and, consequently, the nurse should avoid positioning the patient supine. Oxygen supplementation may or may not be necessary and activity does not always need to be curtailed. Deep breathing and coughing exercises do not directly address this symptom.
You might also like to view...
A nurse is looking for the best interventions for postoperative pain control. When are the facility's policies and procedures an appropriate source of evidence?
a. When policies are based on high-quality clinical practice guidelines b. When evidence is derived from a valid and reliable quantitative research study c. When procedures originated from opinions of the facility's chief surgeon d. When evidence is founded on recommendations from experienced nurses
A parent asks the nurse about the "characteristics of a sleep terror." What response should the nurse give to the parent? (Select all that apply.)
a. The child screams during the sleep terror. b. Return to sleep is delayed because of persistent fear. c. The night terror occurs during the second half of night. d. The child has no memory of the dream with a sleep terror. e. The child is not aware of another's presence during a sleep terror.
Counting the number of persons who are homeless at a particular point in time is called:
1. Census 2. Point prevalence 3. Community assessment 4. Local survey
When a psychiatric technician questions the nurse about comorbidity of eating disorders, which Axis I disorder would the nurse say is most commonly seen in clients with bulimia and anorexia nervosa?
1. Anxiety disorders 2. Depressive disorders 3. Dissociative disorders 4. Somatoform disorders