In which position would the nurse place a 20 year old adult with asthma who is short of breath?
Supine
Trendelenberg
High-Fowler
Semi-Fowler
Left-lateral
The Correct Answer is C
A. Supine is not recommended, as it can make breathing more difficult by limiting chest expansion.
B. Trendelenberg is not suitable for someone with breathing difficulties, as this position can worsen dyspnea.
C. High-Fowler is the best position for an asthma patient experiencing shortness of breath as it promotes lung expansion and allows for maximum chest wall movement.
D. Semi-Fowler may help but is less effective than High-Fowler in cases of acute respiratory distress.
E. Left-lateral does not optimize chest expansion and is not typically recommended for respiratory distress.
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Correct Answer is B
Explanation
A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.
Correct Answer is ["A","C","D"]
Explanation
A. A febrile state indicates that the client may not be in an optimal condition to learn effectively, so postponing the session is appropriate.
B. Mild anxiety may not require postponement, as it can be addressed during teaching.
C. Nausea can significantly impair concentration and engagement in learning, warranting a delay.
D. A pain level of 8 out of 10 suggests significant discomfort, making it challenging for the client to focus on learning.
E. Asking questions indicates engagement and a readiness to learn, so this does not warrant postponing the session.