A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?
Instruct the client to use pursed-lip breathing.
Plan to have the client lay down for 1 hr after meals.
Restrict the client’s fluid intake to less than 1 L/day.
Encourage the client to use the upper chest for respiration.
The Correct Answer is A
Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.
Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.
Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.
It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.
Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should report the situation to the hospital ethics committee, which is used to resolve ethical dilemmas in the health care setting. The hospital ethics committee can help the nurse and the client’s family reach a consensus on the best course of action for the client.
Choice A is wrong because a clinical education specialist is not directly involved in the client’s care and does not have the authority to intervene in ethical issues.
Choice B is wrong because a quality improvement committee is responsible for monitoring and evaluating the quality of care and services provided by the facility, not for addressing ethical conflicts.
Choice D is wrong because a hospital administrator is not usually involved in the clinical decision-making process and may not have the expertise or time to deal with ethical issues.
Correct Answer is C
Explanation
The client may have a ruptured appendix, which is a life-threatening complication of appendicitis. A ruptured appendix can cause peritonitis, which is an infection of the lining of the abdomen, or an abscess, which is a collection of pus around the appendix. These conditions require immediate medical attention and surgery to remove the appendix and clean the abdominal cavity.
Choice A is wrong because administering the prescribed medication may mask the symptoms of a ruptured appendix and delay diagnosis and treatment.
Choice B is wrong because repositioning the client and applying a heating pad may increase the risk of rupture or spread of infection.
Choice D is wrong because calling the operating room team is not the nurse’s responsibility and may not be feasible depending on the availability of the surgical team and the operating room.
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