The nurse enters the room of a patient who is acutely short of breath. Which action should the nurse take first?
a. Assist the patient into Sims' position.
b. Encourage use of pursed-lip breathing.
c. Ask the patient what caused the dyspnea.
d. Teach the patient use of accessory muscles.
ANS: B
Pursed-lip breathing can help open alveoli and promote excretion of carbon dioxide. A. Fowler's, not Sims', position will help lung expansion. C. Asking the patient the cause is appropriate after the dyspnea is resolved. D. Accessory muscle use is a sign of respiratory distress, not a therapeutic measure.
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