A client with asthma reports "not being able to take deep breaths." The nurse auscultates decreased breath sounds in the bases, and no wheezes. What is the nurse's best action?
a. Encourage the client to stay calm and take deep breaths.
b. Document the findings and continue to monitor.
c. Have the client cough forcefully.
d. Assess the client's oxygen saturation.
D
Decreased wheezing accompanied by decreased breath sounds can mean airway occlusion from mucus and from inflammation. The nurse should assess the client's oxygenation and determine whether additional interventions are needed. Coughing forcefully may cause the smaller airways to collapse and may not help the client. Encouraging the client to remain calm and to try to take deep breaths is not helpful. Although providing documentation is important, the nurse needs to do more than that.
You might also like to view...
The OR nurse is participating in the appendectomy of a 20 year-old female patient who has a dangerously low body mass index. The nurse recognizes the patient's consequent risk for hypothermia
What action should the nurse implement to prevent the development of hypothermia? A) Ensure that IV fluids are warmed to the patient's body temperature. B) Transfuse packed red blood cells to increase oxygen carrying capacity. C) Place warmed bags of normal saline at strategic points around the patient's body. D) Monitor the patient's blood pressure and heart rate vigilantly.
What is the term for the passage of water containing dissolved materials through a membrane as the result of a greater mechanical force on one side?
a. Metabolism b. Mitosis c. Filtration d. Osmosis
An 81-year-old female client has presented to the emergency department accompanied by her daughter with whom she lives. The daughter states that her mother has experienced a recent series of falls, which have resulted in her facial and arm bruises
The client smells of urine and is noticeably emaciated, unkempt, and is anxious while the daughter berates her during the nurse's assessment. What is the nurse's responsibility in this situation? A) Determine the daughter's legal status with regard to her mother's financial affairs. B) Report suspected elder abuse to the Adult Protective Services Department. C) Establish whether the client has a durable power of attorney in place. D) Obtain medical records regarding prior admissions for similar problems.
To assess a client for nocturia, the nurse should ask which question?
a. How long can you postpone urination? b. How many times do you wake up at night and urinate? c. Do you leak urine or lose bladder control? d. Do you feel you completely empty your bladder?