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: A durable power of attorney for health care is a type of advance directive that allows the client to designate a person who can make health care decisions for them if they become incapacitated. This is a valid statement by the client that shows an understanding of the teaching.
Choice B reason: A living will is another type of advance directive that specifies the client's wishes regarding life-sustaining treatments. A family member does not need to co-sign the living will for it to be valid. This is an incorrect statement by the client that shows a misunderstanding of the teaching.
Choice C reason: The doctor does not need to provide approval for the decisions outlined in the living will. The living will is a legal document that expresses the client's preferences and values. The doctor should respect and follow the living will as much as possible. This is an incorrect statement by the client that shows a misunderstanding of the teaching.
Choice D reason: The client should not wait until they have a serious health problem to sign their advance directives. The client should sign their advance directives when they are mentally competent and able to communicate their wishes. This is an incorrect statement by the client that shows a misunderstanding of the teaching.
Correct Answer is D
Explanation
Choice A reason: Diminished hand-to-mouth coordination is a finding that indicates a motor deficit, not a speech or language problem. The nurse should refer the client to a physical therapist or an occupational therapist for this issue.
Choice B reason: Altered level of consciousness is a finding that indicates a cognitive impairment, not a speech or language problem. The nurse should monitor the client's mental status and report any changes to the provider.
Choice C reason: Unilateral ptosis is a finding that indicates a cranial nerve deficit, not a speech or language problem. The nurse should assess the client's eye movements and facial symmetry and report any abnormalities to the provider.
Choice D reason: Impaired voluntary cough is a finding that indicates a swallowing disorder, which is a speech or language problem. The nurse should refer the client to a speech-language pathologist for further evaluation and intervention. The client may have dysphagia, which can increase the risk of aspiration and pneumonia.
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