Appropriate nursing actions for a client with dyspnea would include which of the following?
a. auscultating lungs every 4 hours
b. closing privacy curtains or room doors at all times
c. including regular periods for exercise
d. placing the client in the Sims' position
A
Dyspnea may develop as a result of fluid accumulation in the chest, respiratory infections, fibrosis, or anemia. The nurse should monitor the client for any respiratory complications and for oxygen status via pulse oximetry. Placing the client in high Fowler's position helps improve ventilation. Minimizing client activity will also balance oxygen requirements and supply, and improving air flow around the client's unit is also helpful.
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The new mother tells the nurse that sometimes her infant seems to become frantic when crying and asks what she can do when this happens. Which actions would the nurse recommend? Standard Text: Select all that apply
1. Offer breast or bottle if it has been two hours or longer since the last feeding. 2. If the infant is not hungry or wet, allow the infant to cry it out. 3. Swaddle the infant in a blanket and rock the infant. 4. Try patting the infant on the back to help the baby expel gas. 5. Take the infant to a different room or outside to distract the infant.
A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond?
a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe. This is an autosomal dominant disorder that skips generations." c. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify abnormal polyps early."
Xanthine bronchodilators such as theophylline are believed to act by:
a. stimulating adrenergic receptors. b. increasing the rate of secretion of respiratory tract fluid. c. increasing the concentration of intracellular cyclic AMP (cAMP). d. promoting skeletal muscle relaxation.
One day after giving birth vaginally, a client develops painful vesicular lesions on her perineum and vulva. She is diagnosed with a primary herpes simplex 2 infection. What is the expected care for her neonate?
1. Meticulous hand washing and antibiotic eye ointment administration. 2. Intravenous acyclovir (Zovirax) and contact precautions. 3. Cultures of blood and CSF and serial chest x-rays every 12 hours. 4. Parental rooming-in and four intramuscular injections of penicillin.