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Difficulty: EasyBasic Care and Comfort

A nurse is providing night-shift care for an older adult client who is experiencing severe orthopnea and reports difficulty breathing while lying down. Which of the following actions should the nurse take to best promote the client's comfort?

  1. Assist the client to sit upright and lean forward over an overbed table.Answer
  2. B
    Place the client in a flat, supine position to maintain optimal spinal alignment.
  3. C
    Delegate the assessment of the client's respiratory status to the unlicensed assistive personnel (UAP).
  4. D
    Reassure the client that experiencing breathlessness at night is a normal physiological change of aging.

Answer

Assist the client to sit upright and lean forward over an overbed table.
Assisting the client to sit upright and lean forward over an overbed table, known as the orthopneic position, promotes maximum lung expansion. It uses gravity to pull the abdominal organs away from the diaphragm, which significantly reduces the work of breathing and increases comfort for a client experiencing orthopnea.

Step-by-Step Solution

1
Identify the primary physiological issue causing the client's discomfort.
The client is experiencing orthopnea, which is difficulty breathing when lying flat.
Accurately identifying the symptom is required to select the correct comfort and positioning intervention.
2
Select the nursing intervention that directly addresses the respiratory discomfort.
The orthopneic position is selected as the primary intervention.
Sitting upright and leaning forward uses gravity to pull abdominal organs down, allowing the diaphragm to expand fully and reducing the work of breathing.

Key Concept

Non-pharmacological comfort measures and positioning for clients experiencing orthopnea.
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Topics

Basic Care and Comfort

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