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 D
Explanation
Choice A rationale
Performing an opening move is an initial step in the negotiation process where each party presents their initial demands or offers. This is not the step the nurse manager is using in this scenario.
Choice B rationale
Continuing the negotiation involves ongoing discussions and adjustments to reach a mutually beneficial agreement. This is not the step the nurse manager is using in this scenario.
Choice C rationale
Clarifying the problem involves understanding and defining the issues at hand. While this is an important step in the negotiation process, it is not the step the nurse manager is using in this scenario.
Choice D rationale
Setting ground rules involves establishing the guidelines for how the negotiation will be conducted. In this scenario, the nurse manager is setting ground rules by inviting the staff to each take a turn speaking and requesting that everyone listen respectfully and refrain from making personal or professional comments about one another.
Correct Answer is B
Explanation
Choice A rationale
Establishing a benchmark to identify a standard of performance is a crucial step in any quality improvement process. It provides a reference point against which progress can be measured. However, it does not directly evaluate the effectiveness of the implemented measures.
Choice B rationale
Comparing the number of medication errors before and after the implementation of the measures is the most direct and effective method to evaluate the success of the changes. This method provides quantitative data that can clearly show whether the measures have led to a reduction in medication errors.
Choice C rationale
Conducting a study on the time and cost implications of implementing the change can provide valuable information about the efficiency of the measures. However, it does not directly assess their effectiveness in reducing medication errors.
Choice D rationale
Providing a questionnaire to the staff to quantify their satisfaction with the changes can help to assess the acceptance of the measures among the staff. However, staff satisfaction does not necessarily correlate with the effectiveness of the measures in reducing medication errors.
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