A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: A

Rationale: Pleuritic pain, caused by inflamed pleural surfaces rubbing during respiration, intensifies with deep breathing, coughing, or movement, necessitating interventions that minimize these triggers. Avoiding actions that cause deep breathing such as excessive activity or forced respiratory exercises reduces pleural friction, alleviating pain and improving patient comfort, a primary nursing goal. Ambulation thrice daily, while beneficial for circulation, may exacerbate pain by increasing respiratory effort, countering pain management aims. A soft diet and fluids address hydration or swallowing but don't directly relieve pleuritic pain, which is unrelated to nutrition. Limiting speech is unnecessary, as it minimally affects chest movement compared to breathing. By prioritizing rest and shallow breathing, the nurse mitigates pain's impact on recovery, potentially supplementing with analgesics, aligning with holistic care for conditions like pleurisy or pneumothorax.

Correct Answer: C

Rationale: In ARDS, hypotension often results from hypovolemia due to capillary leakage, where fluid shifts into interstitial spaces and alveoli, reducing circulating volume. Toxic fume inhalation damages alveolar-capillary membranes, increasing permeability (non-cardiogenic pulmonary edema), a hallmark of ARDS pathophysiology. This fluid loss, compounded by potential positive end-expiratory pressure (PEEP) reducing venous return, lowers blood pressure. Pulmonary hypotension isn't a recognized term; pulmonary hypertension may occur in ARDS from hypoxic vasoconstriction but doesn't directly cause systemic hypotension. High PEEP can decrease cardiac output by compressing thoracic vessels, but increased cardiac output isn't typical. The nurse's understanding of hypovolemia guides fluid resuscitation and vasopressor use, balancing oxygenation (via PEEP) and perfusion, critical in managing ARDS's systemic effects.

Correct Answer: C

Rationale: During an asthma attack, the preferred intervention is an inhaled beta-adrenergic agonist (e.g., albuterol), which rapidly relaxes bronchial smooth muscle, reversing airflow obstruction from bronchospasm, mucus, and inflammation. This short-acting bronchodilator acts within minutes, opening airways and relieving acute dyspnea, aligning with asthma guidelines (e.g., GINA) for exacerbations. Corticosteroids reduce inflammation but take hours, unsuitable for immediate relief. Anticholinergics (e.g., ipratropium) complement beta-agonists in severe cases but aren't first-line alone. Peak flow monitoring assesses obstruction severity, not treating it. The nurse's swift administration via inhaler ensuring proper technique (e.g., spacer use) restores ventilation, critical for this child's acute respiratory crisis, preventing escalation to status asthmaticus.

Correct Answer: C

Rationale: For a COPD client, diaphragmatic breathing is a key exercise to include in discharge teaching, retraining the patient to use the diaphragm over accessory muscles. This technique inhaling to expand the abdomen, exhaling to contract it reduces respiratory rate, enhances alveolar ventilation, and eases dyspnea by countering the shallow, rapid breathing typical in COPD's hyperinflated state. Lying supine restricts diaphragm movement, worsening air trapping. Pursed-lip breathing, far from avoided, slows expiration, preventing airway collapse a complementary skill. Chest breathing relies on upper thorax muscles, inefficient in COPD. The nurse's teaching on diaphragmatic breathing demonstrated with hand placement (e.g., on abdomen) improves oxygenation and energy efficiency, vital for home management, per respiratory therapy evidence.