A nurse working in the respiratory unit is caring for a client admitted for end stage COPD. Upon assessment the client's skin is pink, respirations are 13 bpm and saturations are 92% on 6 liters via nasal cannula. The client is complaining of shortness of breath while laying down. What should be the nurse's first priority action?

Retake the vital signs.

Call the health care provider.

Place the client in Fowler's position.

Increase the oxygen rate.

Answer and Explanation

The Correct Answer is C

A) Retake the vital signs:
While taking vital signs is important, the client’s vital signs (respiratory rate of 13 bpm, oxygen saturation of 92%, and normal skin color) suggest that there is no immediate crisis, such as a sudden drop in oxygen saturation or significant hemodynamic instability. Therefore, retaking the vital signs would not address the most urgent issue at the moment, which is the client's shortness of breath while laying down.

B) Call the healthcare provider:
Calling the healthcare provider may eventually be necessary if the patient's condition worsens or remains unrelieved after interventions. However, the first priority should be to manage the client’s immediate symptoms and improve their comfort. The client’s complaint of shortness of breath when lying down suggests that the positioning may be a contributing factor to their discomfort.

C) Place the client in Fowler's position:
The most appropriate first action for a client with end-stage COPD and shortness of breath while lying down is to place the client in Fowler's position. This position (sitting upright, typically at a 45-60° angle) helps to improve lung expansion and reduce the workload of breathing by using gravity to assist in lung ventilation. It also promotes diaphragmatic breathing, which can relieve the feeling of breathlessness.

D) Increase the oxygen rate:
The client is already on 6 liters of oxygen via nasal cannula and has an oxygen saturation of 92%, which is within an acceptable range for a patient with COPD. Increasing the oxygen rate further could risk causing oxygen toxicity or lead to CO2 retention in clients with COPD, as their respiratory drive is often driven by low oxygen levels rather than high carbon dioxide levels. Thus, increasing the oxygen rate should be done cautiously and only if clinically indicated by a healthcare provider.

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Correct Answer is B

Explanation

A) Limit fluid intake:
There is no evidence to suggest that limiting fluid intake is necessary or beneficial for clients with multiple sclerosis (MS). In fact, staying well-hydrated is often encouraged, especially for individuals with bladder dysfunction or those at risk for urinary retention or constipation, which are common symptoms of MS. Restricting fluid intake could exacerbate these issues and is not a priority in MS management.

B) Utilize assistive devices as needed:
The most important aspect of teaching for a client recently diagnosed with multiple sclerosis is to encourage the use of assistive devices as needed. MS often causes mobility issues, weakness, and coordination difficulties due to damage to the nervous system. Using devices like canes, walkers, or wheelchairs can significantly improve independence and safety, helping the client maintain mobility and prevent falls

C) Schedule eye examinations every other year:
Eye problems, such as optic neuritis or diplopia (double vision), are common in MS, but the frequency of eye exams depends on the individual’s symptoms. Regular eye exams are important, but every other year is generally not frequent enough. Most MS patients are advised to have annual eye exams or as recommended by their ophthalmologist, especially if they experience any changes in vision.

D) Double up on any missed scheduled medications:
Doubling up on missed medications is not recommended, as it can lead to overdose or increase the risk of side effects. It is important to follow the prescribed medication regimen and use strategies to help the client remember their medications, such as setting reminders or using a medication organizer.

A. "Are you having any headaches?" B. "How has your appetite been?" C. "Does your urine look clear or cloudy? " D. "Are you having trouble with spasms?"

Correct Answer is D

Explanation

A. "Are you having any headaches?" : While headaches can be a side effect of medications, this question does not directly assess the effectiveness of baclofen. Baclofen is primarily used to reduce muscle spasms and improve muscle tone.

B. "How has your appetite been?": Changes in appetite can be related to many factors, including medication side effects, but this question does not address the primary purpose of baclofen, which is to manage muscle spasms.

C. "Does your urine look clear or cloudy?": The appearance of urine is not directly related to the effectiveness of baclofen. This question might be more relevant to assessing other conditions or medications that affect the urinary system.

D. "Are you having trouble with spasms?": Baclofen (Lioresal) is prescribed to manage and reduce muscle spasms in conditions like multiple sclerosis. Asking the client about their experience with muscle spasms directly assesses the effectiveness of the medication in managing their symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing discharge teaching for a client who is recently diagnosed with Multiple sclerosis. Which of the following is the most important to include in the patient teaching?

Correct Answer is B

Explanation

A home health nurse is making a home visit to a client with multiple sclerosis. The nurse reviews the home medications taken by the client. Which question should the nurse ask to determine the effectiveness of the client's medication, baclofen (Lioresal)?

Correct Answer is D

Explanation

The nurse is caring for a client with uterine cancer who is being treated with brachytherapy. The UAP reports that the client ambulated to the restroom and is now reporting, "something feels like it’s coming out." What is the nurse's priority action?

A nurse is assessing a client who has early symptoms of hypoxia. Which of the following findings should the nurse expect?

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require immediate intervention?

A nurse in the med-surgical ICU is evaluating a patient with a diagnosis of chronic copd. The patient is receiving oxygen at a flow rate of 10 L/min via facemask. Which finding would concern the nurse to act immediately?

A nurse is caring for a client who taking benztropine to treat Parkinson's disease. The nurse should instruct the client to monitor and report which of the following side effects of benztropine?

A nurse in the respiratory unit is caring for client who has a past medical history of heart failure and is currently admitted for asthma exacerbation. When reviewing the provider's orders further clarification is needed for which of the following medications?

A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse prepare to take first?