A home health nurse visits a client with COPD who is receiving oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?
Call emergency services for the client
Have the client cough and expectorate secretions
Increase the oxygen flow to 3 L/min
Assess the client's respiratory status
The Correct Answer is D
A. Call emergency services for the client — While this may be necessary if the client is in severe distress, the nurse must first assess the situation to determine the appropriate level of intervention.
B. Have the client cough and expectorate secretions — This can help if secretions are causing the breathing difficulty, but assessment should come first to identify the cause.
C. Increase the oxygen flow to 3 L/min — Increasing oxygen in a client with COPD can be dangerous without proper assessment, as it may suppress their respiratory drive.
D. Assess the client's respiratory status — This is the priority action. The nurse must first gather data (e.g., respiratory rate, effort, oxygen saturation, lung sounds) to determine the appropriate next steps in care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Clients with heart failure should notify the provider for a weight gain of 2–3 pounds in a day or 5 pounds in a week, not just 1 pound.
B. Diuretics should be taken early in the morning to avoid nocturia; taking them before bedtime can disrupt sleep.
C. Regular exercise, such as walking at least three times a week, helps improve cardiac function, endurance, and overall health and is appropriate for clients with heart failure.
D. Naproxen and other NSAIDs can cause fluid retention and may worsen heart failure; they should generally be avoided in these clients.
Correct Answer is B
Explanation
A. The client should see improvement in condition in 2 days — Levothyroxine typically takes 1 to 3 weeks for therapeutic effects to be noticeable.
B. Take on an empty stomach — Levothyroxine should be taken on an empty stomach, ideally 30 to 60 minutes before breakfast, to enhance absorption.
C. It is ok to skip doses — Levothyroxine should be taken consistently every day to maintain stable hormone levels. Skipping doses can lead to symptom recurrence.
D. Notifying the health care provider is unnecessary if you experience a fast heartbeat — A fast heartbeat (tachycardia) may indicate overmedication and should be reported to the healthcare provider promptly.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.