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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Efficiency in healthcare refers to the optimal use of resources to achieve the desired health outcomes. Reducing wait times in the emergency department is an example of improving efficiency, as it involves streamlining processes to provide timely care.
Choice B rationale
Utilizing the CAUTI bundle to prevent urinary tract infections when placing indwelling urinary catheters is more related to the safety and effectiveness domains of healthcare quality.
Choice C rationale
Using an interpreter for patients who do not speak the healthcare provider’s language is related to the equity and patient-centeredness domains of healthcare quality.
Choice D rationale
Opening and utilizing supplies that are necessary for the task is a basic requirement in healthcare, but it does not specifically relate to the efficiency domain of healthcare quality.
Correct Answer is B
Explanation
Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
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