A charge nurse is teaching a newly licensed nurse about caring for a client who has COPD. Which of the following instructions should the charge nurse include in the teaching?
Call the provider if you note clubbing of the client's fingernails.
Have an assistive personnel ambulate the client just before meals.
Notify me if you observe that the client has distended neck veins.
Maintain the client's oxygen saturation level above 95 percent.
The Correct Answer is C
Choice A reason: Calling the provider if you note clubbing of the client's fingernails is not an instruction the charge nurse should include in the teaching. This is an unnecessary and inappropriate action, as clubbing is a chronic and irreversible sign of hypoxia that does not require immediate intervention. The nurse should document the finding and monitor the client's respiratory status.
Choice B reason: Having an assistive personnel ambulate the client just before meals is not an instruction the charge nurse should include in the teaching. This is a harmful and contraindicated action, as ambulation can increase the client's oxygen demand and cause dyspnea and fatigue. The nurse should schedule the client's activity and rest periods around the meals and provide supplemental oxygen as prescribed.
Choice C reason: Notifying the charge nurse if you observe that the client has distended neck veins is an instruction the charge nurse should include in the teaching. This is a necessary and appropriate action, as distended neck veins can indicate right-sided heart failure, which is a complication of COPD. The nurse should report the finding and assess the client for other signs of fluid overload, such as edema, weight gain, and crackles.
Choice D reason: Maintaining the client's oxygen saturation level above 95 percent is not an instruction the charge nurse should include in the teaching. This is an unrealistic and potentially harmful goal, as clients with COPD usually have lower oxygen saturation levels due to chronic hypoxia. The nurse should maintain the client's oxygen saturation level at the prescribed range, which is typically between 88 and 92 percent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Providing the client with written information in their spoken language is the appropriate action for the nurse to take. This would ensure that the client understands the information and can refer to it later. It would also respect the client's culture and preferences.
Choice B reason: Speaking very slowly during the teaching session is not an appropriate action for the nurse to take. This would not improve the communication or comprehension of the client. It might also be perceived as patronizing or disrespectful by the client.
Choice C reason: Using medical terminology while explaining the medications is not an appropriate action for the nurse to take. This would confuse the client and hinder the learning process. The nurse should use simple and clear language that the client can understand.
Choice D reason: Having the client's family member who is present interpret is not an appropriate action for the nurse to take. This would compromise the accuracy and confidentiality of the information. It might also create a conflict of interest or a bias for the family member. The nurse should use a professional interpreter or a translation device if available.
Correct Answer is D
Explanation
Choice A reason: A middle adult client who leaves the facility against medical advice does not require the involvement of the ethics committee. The nurse should document the client's decision, inform the provider, and provide discharge instructions.
Choice B reason: A young adult client who is participating in a medical research study does not require the involvement of the ethics committee. The nurse should ensure that the client has given informed consent and is aware of the potential risks and benefits of the study.
Choice C reason: An older adult client who has advance directives on file does not require the involvement of the ethics committee. The nurse should respect the client's wishes and follow the directives in case of a life-threatening situation.
Choice D reason: An adolescent client whose parents refuse a blood transfusion for religious reasons requires the involvement of the ethics committee. The nurse should consult the ethics committee to help resolve the conflict between the parents' beliefs and the client's best interests. The ethics committee can also provide guidance on the legal and ethical implications of the situation.
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