Difficulty: Medium
Average Score: 63%
Simulated
Passage / Scenario
At 1930 the nurse notes that the client has rapid, more labored respirations with frequent coughing that is producing thick tenacious secretions. The client is alert and oriented and able to speak, between coughing episodes. She states that the last time she had this much coughing, the respiratory therapist (RT) gave her a nebulizer treatment, which 'helped a lot.'What nursing actions would the nurse implement at this time in coordination with the registered nurse (RN)? Select all that apply.
Correct answer
B, D, E, F
Rationale
Obtaining vital signs (B), positioning in high-Fowler (D), increasing oxygen flow (E), calling for a nebulizer treatment (F), documenting (H), and listening to breath sounds (J) address the client's respiratory distress and monitor status effectively.