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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: The client's vital signs are not part of the background information, but rather the assessment information. The background information should include relevant and concise data about the client's history, diagnosis, and treatment.

Choice B reason: The client's name is part of the background information, as it identifies the client and establishes rapport. The name should be the first thing the nurse says when initiating the SBAR communication.

Choice C reason: The client's code status is not part of the background information, but rather the recommendation information. The code status should be communicated at the end of the SBAR communication, along with any other suggestions or requests for the receiving nurse.

Choice D reason: A prescribed consultation is not part of the background information, but rather the situation information. The situation information should describe the current problem or reason for the transfer.

A. Report of photophobia B. Increased temperature C. Decreased level of consciousness D. Generalized rash over trunk

Correct Answer is C

Explanation

Choice A reason: Report of photophobia is a common finding in clients who have meningitis, as the inflammation of the meninges causes sensitivity to light. However, this is not an urgent finding that requires immediate reporting to the provider.

Choice B reason: Increased temperature is a common finding in clients who have meningitis, as the infection causes fever and systemic inflammation. However, this is not an urgent finding that requires immediate reporting to the provider, unless it is very high or accompanied by other signs of sepsis.

Choice C reason: Decreased level of consciousness is an urgent finding in clients who have meningitis, as it indicates increased intracranial pressure, cerebral edema, or brain herniation. These are life-threatening complications that require immediate intervention and treatment.

Choice D reason: Generalized rash over trunk is a common finding in clients who have meningococcal meningitis, as the bacteria cause petechiae and purpura on the skin. However, this is not an urgent finding that requires immediate reporting to the provider, unless it is extensive or associated with bleeding or shock.

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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?

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