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.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: A client who has peripheral vascular disease and has an absent pedal pulse in the right foot is at risk of tissue ischemia and necrosis, which are serious complications. However, this is not the highest priority, as the condition is chronic and not acute.
Choice B reason: A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy is facing a life-threatening illness and needs emotional and physical support. However, this is not the highest priority, as the client is stable and not experiencing any immediate complications.
Choice C reason: A client who has MRSA and has an axillary temperature of 38°C (101°F) has an infection that can spread to other clients and staff, and needs isolation and antibiotic therapy. However, this is not the highest priority, as the fever is mild and the infection is treatable.
Choice D reason: A client who is postoperative following a laminectomy 12 hr ago and is unable to void has urinary retention, which can lead to bladder distension, pain, infection, and renal damage. This is the highest priority, as the client needs immediate intervention to relieve the obstruction and prevent further complications.
Correct Answer is A
Explanation
Choice A reason: The state nurse practice act is an appropriate resource for the nurse to consult in planning for this policy. The state nurse practice act defines the scope of practice and the legal authority for nurses in each state. The nurse should ensure that the policy is consistent with the state regulations and does not exceed the nurse's level of competence and education.
Choice B reason: The ANA Standards of Practice are not the most appropriate resource for the nurse to consult in planning for this policy. The ANA Standards of Practice describe the expectations and responsibilities for the professional nursing practice, such as assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The standards are general and broad, and do not provide specific guidance on the procedure of removing chest tubes.
Choice C reason: The ANA Code of Ethics is not the most appropriate resource for the nurse to consult in planning for this policy. The ANA Code of Ethics outlines the ethical principles and values that guide the nursing practice, such as respect, autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity. The code does not address the technical or legal aspects of removing chest tubes.
Choice D reason: The Institute of Medicine is not the most appropriate resource for the nurse to consult in planning for this policy. The Institute of Medicine is an independent, nonprofit organization that provides evidence-based recommendations and research on health care issues, such as quality, safety, and innovation. The institute does not regulate or define the nursing practice or scope.
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