Author Question: A client with terminal lung cancer is experiencing shortness of breath. The nurse notes bilateral ... (Read 111 times)

nummyann

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A client with terminal lung cancer is experiencing shortness of breath. The nurse notes bilateral crackles and wheezes, despite oxygen at 4 liters per minute via nasal cannula and diuretic therapy.
 
  What nursing interventions are most appropriate for this client?
  Select all that apply.
  A) Elevate the head of the client's bed to a Fowler's position.
  B) Change the client's oxygen therapy to a nonrebreathing mask.
  C) Administer morphine sulfate per physician order.
  D) Move the client to a room closer to the nurse's desk for closer observation.
  E) Place a fan in the room to move air around the client.

Question 2

The home care nurse hears the spouse of an older client say You have been so sick but you insist on living in this huge home that you cannot maintain but expect me to.
 
  The client engages in an argument with the spouse. Which does the home care nurse identify as occurring with this couple?
  A) Evidence of low blood glucose levels
  B) Financial struggles within the family
  C) Possible situational depression for both client and spouse
  D) Spousal abuse



succesfull

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Answer to Question 1

Answer: A, C, E

Placing a fan to circulate air, elevating the head of the bed, and using morphine sulfate may relieve the client's shortness of breath. Moving the client who is short of breath is not advisable. Lateral positions are appropriate for unconscious clients, but this client is conscious. Conscious clients who are short of breath do not tolerate oxygen therapy by mask.

Answer to Question 2

Answer: C

Manifestations associated with situational depression in the older client include irritability and poor work performance. One spouse is irritable because of overwork and the other spouse is irritable because of the inability to perform household work. The nurse cannot determine if the family is having financial struggles. There is no evidence of spousal abuse at this time. The nurse cannot determine that the arguing is due to low blood glucose levels.



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