A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

Encourage the client to take breaks from oxygen use to prevent tolerance.

Maintain nasal oxygen at a 1 to 2 liter/minute flow rate.

Assess cheeks and posterior ears for signs of skin breakdown.

Teach the client how to safely increase oxygen flow when they deem necessary.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While it is important to monitor oxygen use to prevent hypoxia and hypercapnia, taking breaks from oxygen use is not typically recommended for clients with COPD. These clients often require supplemental oxygen to maintain adequate oxygen saturation.
Choice B rationale
Maintaining a low flow rate of oxygen is crucial in clients with COPD. These clients are often “CO2 retainers,” and administering a high concentration of oxygen can suppress their respiratory drive, leading to further CO2 retention and respiratory distress.
Choice C rationale
While it is important to assess for signs of skin breakdown in clients receiving oxygen therapy, this is not the priority when administering nasal oxygen to a client with COPD38.
Choice D rationale
Clients should not adjust their oxygen flow rate without medical supervision. Increasing the oxygen flow rate can lead to hyperoxia, which can be harmful, especially in clients with COPD who are CO2 retainers.

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Correct Answer is B

Explanation

Choice A rationale
Reports routinely listing the identification number of any equipment involved is not a problem. This is a standard practice in incident reporting as it helps in identifying and tracking the equipment involved in the incident.
Choice B rationale
Reports routinely omitting the names of witnesses to the occurrence is a problem that should be reported to the risk manager. Witnesses can provide crucial information about the incident, and their statements can help in understanding the sequence of events and identifying the root cause of the incident.
Choice C rationale
Reports being completed within 24 hours after the incident is not a problem. Timely reporting of incidents is crucial for accurate recall of events and immediate initiation of corrective actions.
Choice D rationale
Reports routinely including the client’s hospital number is not a problem. This is a standard practice in incident reporting as it helps in identifying and tracking the patient involved in the incident.

A. Place a tracheostomy tray at the client’s bedside. B. Administer IV prophylaxis for thromboembolism. C. Prepare to assist with intubation of the client. D. Administer IV prophylaxis for stress ulcers.

Correct Answer is C

Explanation

Choice A rationale
Placing a tracheostomy tray at the client’s bedside is not the first action a nurse should take when a client is diagnosed with ARDS. While a tracheostomy may be necessary in some cases, it is not the immediate priority.
Choice B rationale
Administering IV prophylaxis for thromboembolism is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.
Choice C rationale
Preparing to assist with intubation of the client is the first action a nurse should take when a client is diagnosed with ARDS. Intubation and mechanical ventilation are often required to ensure adequate oxygenation in clients with ARDS3.
Choice D rationale
Administering IV prophylaxis for stress ulcers is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.

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A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing incident reports submitted during the previous month. The nurse should identify which of the following as a problem that should be reported to the risk manager?

Correct Answer is B

Explanation

A client has been diagnosed in the Emergency Department with acute respiratory distress syndrome (ARDS). Which of the following actions should a nurse perform first?

Correct Answer is C

Explanation

A nurse is caring for a postoperative client experiencing shallow respirations and refusing to cough or get out of bed to the chair. The nurse should educate the client about the increased risk of which complication?

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A nurse is caring for a client who has a pneumothorax. The nurse is reviewing the client’s medical record. What prescriptions should the nurse anticipate for a client who has a pneumothorax?