Page 97 - Saunders Comprehensive Review For NCLEX-RN

4. Encourage the client to cough and deep breathe.
Answer: 4
Test-Taking Strategy
Use the ABCs—airway, breathing, circulation—as a guide to direct you to the correct
option and note the strategic word, priority. Recall that morphine sulfate suppresses the
cough reflex and the respiratory reflex, and a common adverse effect is respiratory
depression. Coughing and deep breathing can assist with ensuring adequate
oxygenation, since the number of respirations per minute can potentially be decreased
in a client receiving this medication. Although options 1, 2, and 3 are components of the
plan of care, the correct option addresses airway and breathing. Remember to use the
ABCs—airway, breathing, circulation—to prioritize.
1. Use the ABCs—airway–breathing–circulation—when
selecting an answer or determining the order of
priority.
2. Remember the order of priority: airway– breathing–
circulation.
3. Airway is always the first priority. Note that an
exception occurs when cardiopulmonary resuscitation
is performed; in this situation, the nurse follows the
CAB (compressions/circulation–airway–breathing)
guidelines.
F. Maslow’s Hierarchy of Needs theory (Box 4-10; Fig. 4-1)

Box 4-10
Practice Question: Maslow’s Hierarchy of Needs
Theory
The nurse caring for a client experiencing dystocia determines that the priority is which
action?
1. Position changes and providing comfort measures
2. Explanations about what is happening to the client
3. Monitoring for changes in the condition of the mother and fetus
4. Reinforcement of breathing techniques learned in childbirth preparatory classes
Answer: 3
Test-Taking Strategy
All the options are correct and would be implemented during the care of this client.
Note the strategic word, priority, and use Maslow’s Hierarchy of Needs theory to
prioritize, remembering that physiological needs come first. Also, the correct option is
the only one that addresses both the mother and the fetus. Remember to use Maslow’s
Hierarchy of Needs theory to prioritize.

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