The nurse is providing care for a client with cancer of the left lung who will undergo video-assisted thoracic surgery in the morning. The client is nervous, jumpy, and short of breath. Pulse is 120/min, respirations are 30/min and shallow, and expiratory wheezing is auscultated in the left upper and lower lung posteriorly. Which of the following is the priority nursing action?

Question

Quizplus · Accepted Answer

Elevating the head of the bed to Fowler's or high Fowler's position is the priority nursing action to help relieve shortness of breath, facilitate oxygenation (breathing), and promote lung expansion (airway). Alternate positions to high Fowler's include the following: Orthopneic position: Sitting in a chair, on the side, or in bed leaning over the bedside table, with one or more pillows under the arms or elbows for support Tripod position: Sitting in a chair leaning forward with hands or elbows resting on the knees. Sitting upright and leaning forward pulls the scapulae apart, promotes lung expansion, and decreases the diaphragmatic pressure produced by the viscera. (Option A) Morphine is effective in relieving anxiety and decreasing the work of breathing by slowing respirations. It can cause hypoventilation and decrease gas exchange in the lungs and is not the priority action, especially as the client's respirations are shallow. (Option B) The cause of the wheezing could be from lung tumor or true bronchoconstriction. Paging the respiratory therapist to administer a bronchodilator nebulizer treatment to relieve wheezing is an appropriate intervention, but it is not the priority action. (Option D) Encouraging the client to talk about the diagnosis and upcoming surgery is an appropriate intervention to help alleviate anxiety and address self-actualization needs, but is not the priority action. Educational objective: Elevating the head and chest in the Fowler's, high Fowler's, orthopneic, and tripod positions allows for maximum lung expansion and promotes oxygenation, especially in clients with dyspnea.

The Nurse Is Providing Care for a Client with Cancer