A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?
Offer fruit juice at least twice during both the day and evening shifts.
Encourage the client to eat all of the meals that are sent.
Lower the bed prior to helping the client to move up in bed.
Have the client hold a pillow over the abdomen to cough and deep breathe.
The Correct Answer is D
Choice A reason: Offering fruit juice is part of good nutrition and hydration but does not directly assist with the client's breathing difficulty.
Choice B reason: Encouraging the client to eat all meals is important for nutritional support, but it is not the most critical action related to the client's immediate respiratory comfort.
Choice C reason: Lowering the bed may be a safety measure but does not address the client's need for respiratory support.
Choice D reason: Having the client hold a pillow over the abdomen can help splint the chest while coughing, reducing discomfort and facilitating deep breathing, which is essential for a client with emphysema experiencing difficulty breathing.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Offering to contact the family's spiritual counselor can provide emotional and spiritual support, but it is not the immediate priority in a situation where the client has expressed a desire to have life support withdrawn.
Choice B reason: Discussing comfort measures is important for the client and family to understand what to expect during the withdrawal process. However, this step comes after the healthcare provider has been informed and a plan of care is being developed.
Choice C reason: Informing the healthcare provider is the priority nursing intervention. The nurse acts as an advocate for the client's wishes and ensures that the appropriate steps are taken to respect the client's autonomy and decisions regarding their care.
Choice D reason: Explaining the actions that the healthcare team will follow is an essential part of the process, but it is not the first step. The healthcare provider must first be informed so that the proper orders and arrangements can be made.
Correct Answer is C
Explanation
Choice A reason: Modifying nursing interventions is a step that may be necessary after evaluating the effectiveness of care, but it is not the immediate next action after reviewing the expected outcomes.
Choice B reason: Determining if the expected outcomes were realistic is part of the evaluation process, but it requires current data to make an informed decision.
Choice C reason: Obtaining current client data is essential to compare with the expected outcomes and determine if the goals of care are being met.
Choice D reason: Reviewing related professional standards of care is important for ensuring quality care, but it is not the direct next step in evaluating the effectiveness of the client's nursing care.
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