Question

The nurse is working on a medical surgical unit. A client with pancreatitis is complaining of dyspnea. Which is the appropriate initial nursing action? A. Instruct the client to breathe in through the mouth and out via the nostrils B. Elevate the head of the bed C. Notify the healtheare provider D. Assess the vital signs and record them in the client's medical record

Short answer

Answer: Elevate the head of the bed.

Step-by-step solution

Understand the scenario

Assess the client's situation. The client has pancreatitis and is experiencing difficulty breathing (dyspnea). The goal is to determine the best initial nursing action.

Evaluate the given options

For each of the given options, consider their actions and potential immediate benefits to the client: A. Instructing the client to breathe in through the mouth and out via the nostrils: This breathing technique might help the client to calm down but it might not address any underlying cause of the dyspnea. B. Elevating the head of the bed: Doing so can help open up the client's airway and facilitate breathing by decreasing pressure on the diaphragm and promoting lung expansion. C. Notifying the healthcare provider: Although this is an essential step in the care of a client with dyspnea, it should not be the initial action. The nurse should assess and intervene first before updating the healthcare provider. D. Assessing vital signs and recording them in the client's medical record: It is essential to assess the client's vital signs but recording them is not considered an intervention. The nurse needs to do something to help the client first.

Choose the best initial nursing action

Based on the evaluation of the given options, the appropriate initial nursing action for a client with pancreatitis experiencing dyspnea is: B. Elevate the head of the bed This action helps to improve the client's breathing by facilitating lung expansion and decreasing pressure on the diaphragm. Other interventions and further assessment can follow this initial action, such as assessing vital signs and notifying the healthcare provider.