Safe, Effective Care Environment
71. On a skilled nursing unit, an LVN/LPN reports to a staff nurse that a client is short of breath. What is the most important initial response by the RN?
Safe, Effective Care Environment
71. On a skilled nursing unit, an LVN/LPN reports to a staff nurse that a client is short of breath. What is the most important initial response by the RN?
. Ask the LVN/LPN if this is a new symptom.
. Do an independent nursing assessment of the client.
. Ask the LVN/LPN to describe what is meant by shortness of breath.
. Check the client's chart for a current x-ray report.
Test-Taking Tip
Key word: "initial." Note that two options (Answers 1 and 3) focus on asking for more data from the LVN/LPN; choose the one that is likely to provide more information (i.e., "describe").
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 1 is incorrect because it will not provide enough data to make a decision. It may yield only a "yes" or "no" reply. Answer 2 is incorrect because there are insufficient data to warrant this action as a priority for RN intervention. Answer 3 is correct because more information is necessary in order to clarify the urgency of the situation. This information will help delineate and prioritize nursing interventions. Answer 4 is incorrect because, although this is valuable information, it is not the best initial response by the RN.