A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula, is currently short of breath. Which action should the nurse take?
Have the client breathe into a paper bag.
Ask the client to take short, rapid breaths.
Instruct the client in pursed lip breathing.
Increase oxygen to three L/minute.
The Correct Answer is C
A. Having the client breathe into a paper bag is a technique sometimes used for anxiety-induced hyperventilation but is not appropriate for a client with chronic obstructive lung disease
experiencing shortness of breath. It can lead to a buildup of carbon dioxide, worsening the client's condition.
B. Asking the client to take short, rapid breaths may exacerbate hyperventilation and increase the client's anxiety. This breathing pattern can lead to further respiratory distress in a client with
chronic obstructive lung disease.
C. Instructing the client in pursed lip breathing is the most appropriate action. Pursed lip breathing helps to prolong exhalation, reduce air trapping, and improve gas exchange in clients with chronic obstructive lung disease. It can help alleviate shortness of breath and promote
relaxation.
D. Increasing oxygen to three L/minute may not be necessary and could potentially lead to oxygen toxicity. The priority is to help the client manage their shortness of breath effectively through breathing techniques.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Redness and swelling of the calf are classic signs of deep vein thrombosis (DVT), especially in an older adult who is immobile. DVT is a common complication in hospitalized patients, particularly those who are immobile or have other risk factors such as dehydration.
B. Fat emboli typically present with symptoms such as dyspnea, tachypnea, and petechial rash, rather than localized redness and swelling of the calf.
C. Pulmonary embolism typically presents with symptoms such as chest pain, dyspnea, tachypnea, and hemoptysis, rather than localized redness and swelling of the calf.
D. While infection can cause localized redness and swelling, the presence of dehydration and immobility increases the likelihood of a thrombotic event such as deep vein thrombosis. It is important to consider DVT as a potential cause of these findings and initiate appropriate diagnostic and preventive measures.
Correct Answer is A
Explanation
A. Determine if the newborn is in the nursery: This action directly addresses the immediate concern of the missing newborn and ensures prompt verification of the infant's location.
B. Match ID bands of all infants and mothers on the unit: While important for ensuring proper
identification, this action may take longer to complete and should follow the immediate concern of locating the newborn.
C. Activate the lockdown procedure: This extreme measure should only be implemented if there is evidence of a security threat or if there is reason to believe that the newborn has been
abducted.
D. Ask the mother if any visitors were expected to arrive: While obtaining this information may be relevant for investigation purposes, it should not delay the immediate search for the newborn.
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