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 B
Explanation
Choice A reason: Nurses who have advanced training may provide direct care for clients, but this is not specific to case management. Case management is a collaborative process that involves assessing, planning, implementing, coordinating, monitoring, and evaluating the options and services required to meet the client's health and human service needs.
Choice B reason: Nurses use critical pathways when caring for clients as part of case management. Critical pathways are standardized plans of care that outline the expected outcomes, interventions, and time frames for a specific diagnosis or procedure. They help to ensure quality, continuity, and cost-effectiveness of care.
Choice C reason: Nurses delegate and supervise assigned tasks, but this is a general nursing responsibility and not specific to case management. Case management requires more than just task delegation and supervision. It also involves communication, coordination, and evaluation of care.
Choice D reason: The nurse completes one specific task for a group of clients is not an accurate description of case management. Case management is not task-oriented, but client-centered and outcome-focused. The nurse is responsible for the overall care of the client, not just one aspect of it.
Correct Answer is D
Explanation
Choice A reason: While it's essential to use a fire extinguisher during a fire emergency, aiming at the top of the flames is not the correct technique. Fire extinguishers should be aimed at the base of the flames to cut off the oxygen supply and extinguish the fire effectively.
Choice B reason: During a fire, moving client care equipment into the hallway is not recommended. In an emergency, the priority is to ensure the safety of patients and staff. Moving equipment might obstruct evacuation routes or delay the evacuation process.
Choice C reason: This choice is incorrect. Placing dry towels at the base of doors is not a recommended action during a fire. It does not effectively prevent smoke or fire from spreading. Instead, use proper fire-rated door seals or close the doors securely to prevent smoke and flames from entering rooms.
Choice D reason: Closing the windows in client rooms is a correct action during a fire. Closed windows help prevent the entry of smoke and flames, reducing the risk to patients and staff. It also helps maintain a safe environment within the room.
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