A nurse assesses a client with chronic obstructive pulmonary disease.
Which Questions would the nurse ask to determine the client's activity tolerance? (Select all that apply.)
"What color is your sputum?"
"Do you have any difficulty sleeping?"
"How long does it take to perform your morning routine?"
"Do you walk upstairs every day?"
"Have you lost any weight lately?"
"How does your activity compare to this time last year?"
Correct Answer : B,C,D,E
Choice A rationale
"What color is your sputum?" is a question related to the presence of infection or inflammation within the respiratory tract, providing insight into the nature of respiratory secretions. While important for overall respiratory assessment in COPD, it does not directly evaluate the client's functional capacity or activity tolerance.
Choice B rationale
"Do you have any difficulty sleeping?" directly assesses the impact of respiratory symptoms on rest and activity. Dyspnea, especially nocturnal or exertional dyspnea, can significantly impair sleep quality, indicating reduced activity tolerance and the inability of the respiratory system to meet oxygen demands during rest.
Choice C rationale
"How long does it take to perform your morning routine?" evaluates the client's ability to perform activities of daily living (ADLs). A prolonged duration or increased effort required for self-care tasks indicates diminished activity tolerance due to respiratory limitations, reflecting the physiological burden of COPD on daily functioning.
Choice D rationale
"Do you walk upstairs every day?" directly probes the client's capacity for common exertional activities. Walking upstairs is a standardized measure of functional exercise tolerance, and difficulty with this task signifies impaired respiratory reserve and reduced activity tolerance in individuals with chronic obstructive pulmonary disease.
Choice E rationale
"Have you lost any weight lately?" assesses nutritional status and systemic effects of chronic illness, often indicating the increased metabolic demands of breathing in COPD. While important for overall health, weight loss itself is not a direct measure of activity tolerance, but rather a consequence of severe disease progression.
Choice F rationale
"How does your activity compare to this time last year?" provides a valuable longitudinal perspective on the progression of COPD and the client's functional decline or stability. This comparison helps to quantify changes in activity tolerance over time, reflecting the effectiveness of treatment or disease progression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Calculate the milligrams per dose. 600 mg/day ÷ 3 doses/day = 200 mg/dose. The patient will receive 200 mg per dose.
Correct Answer is B
Explanation
Choice A rationale
A peak flow meter measures the maximum speed of exhalation, providing information about airflow obstruction and lung function. While useful for monitoring asthma control, it does not address the patient's difficulty coordinating MDI activation with breathing. It's a diagnostic tool, not a coordination aid.
Choice B rationale
A spacer device is a valved holding chamber that attaches to the MDI. It simplifies inhalation by holding the aerosolized medication, allowing the patient to inhale it slowly and deeply without requiring precise coordination between activation and inspiration. This significantly improves drug delivery to the lungs.
Choice C rationale
Notifying the prescriber that the patient is unable to use the MDI without suggesting solutions is premature. The nurse should first attempt an intervention to resolve the coordination issue, such as suggesting a spacer, as this is a common problem with a well-established solution.
Choice D rationale
While some respiratory medications can be given orally, switching the route of administration should not be the initial intervention for MDI coordination issues. Oral administration can have different pharmacokinetic profiles, systemic side effects, and may not provide the same targeted drug delivery to the airways as inhaled therapy.
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