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 B
Explanation
Choice A rationale
While immunosuppressive drug therapy can facilitate organ rejection, it is not directly related to the development of chronic rhinosinusitis in patients who have undergone organ transplants.
Choice B rationale
Immunosuppressive drug therapy can indeed contribute to chronic rhinosinusitis. Patients who have undergone organ transplants are often on long-term immunosuppressive therapy to prevent organ rejection. This can make them more susceptible to infections, including chronic rhinosinusitis.
Choice C rationale
Chronic rhinosinusitis does not typically damage the transplanted organ. It primarily affects the sinuses and nasal passages.
Choice D rationale
All of the above is not the correct answer because Choices A and C are not accurate in the context of chronic rhinosinusitis in patients who have undergone organ transplants.
Correct Answer is C
Explanation
Choice A rationale
A pH of 7.55, PaCO2 of 30 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 24 mEq/L would indicate respiratory alkalosis, which is not typically associated with progressive COPD67.
Choice B rationale
A pH of 7.40, PaCO2 of 40 mm Hg, PaO2 of 94 mm Hg, and HCO3 of 22 mEq/L represent normal ABG values.
Choice C rationale
A pH of 7.30, PaCO2 of 60 mm Hg, PaO2 of 70 mm Hg, and HCO3 of 30 mEq/L are indicative of respiratory acidosis with metabolic compensation, which is commonly seen in patients with progressive COPD67.
Choice D rationale
A pH of 7.38, PaCO2 of 45 mm Hg, PaO2 of 88 mm Hg, and HCO3 of 26 mEq/L would indicate a slight respiratory acidosis, which is not typically associated with progressive COPD67.
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