Question

The nurse is caring for a client who is in the hospital for exacerbation of emphysema symptoms. The nurse notes shortness of breath and tachypnea. Which of the following actions is most appropriate in response to this?

a) Monitor blood pressure for signs that pressure is increasing
b) Monitor urine output to ensure that it is at least 30 mL/hour
c) Check the client's arterial blood gases
d) Maintain the head of the bed at a minimum 45-degree angle

Answer 1

The most appropriate action in response to the client's symptoms of shortness of breath and tachypnea is to maintain the head of the bed at a minimum 45-degree angle.

Step-by-step explanation:

The most appropriate action in response to the client's shortness of breath and tachypnea would be to maintain the head of the bed at a minimum 45-degree angle. This position helps improve lung expansion and ease breathing in clients with exacerbation of emphysema symptoms. It facilitates optimal ventilation and minimizes the effort required for breathing.

The nurse caring for a client with an exacerbation of emphysema symptoms who exhibits shortness of breath and tachypnea should respond by maintaining the head of the bed at a minimum 45-degree angle. This action, known as positioning the patient in high Fowler's position, improves chest expansion and decreases the work of breathing, aiding in better oxygenation. Although other actions such as monitoring blood pressure, urine output, and checking arterial blood gases (ABGs) may be appropriate in different contexts, they are not the most immediate response required for the patient's shortness of breath and rapid breathing.