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 C

Explanation

A) Bradycardia:
Benztropine is an anticholinergic medication used to manage the symptoms of Parkinson's disease by blocking the action of acetylcholine. While anticholinergic medications can affect heart rate, bradycardia is not a common side effect of benztropine. In fact, benztropine may have the opposite effect, potentially causing tachycardia (increased heart rate).

B) Excess salivation:
Excessive salivation is typically a symptom of Parkinson's disease itself, due to difficulty swallowing, rather than a side effect of benztropine. In fact, benztropine, as an anticholinergic agent, generally reduces salivation (anticholinergic effect), so this side effect is unlikely to occur with benztropine therapy.

C) Urinary retention:
Benztropine, being an anticholinergic drug, can inhibit the action of acetylcholine at muscarinic receptors in the bladder, leading to urinary retention. This is a common and serious side effect of anticholinergic drugs like benztropine. Urinary retention can lead to discomfort, urinary tract infections (UTIs), and kidney problems if not addressed.

D) Diarrhea:
Benztropine is more likely to cause constipation rather than diarrhea due to its anticholinergic effects. Anticholinergic medications often slow down gastrointestinal motility, leading to constipation.

A. Administering oxygen via nasal cannula at 2 U/min B. Helping the client select a low-salt diet C. Maintaining a semi-Fowler's position as often as possible D. Encouraging the client to drink 2 to 3 L of water daily

Correct Answer is D

Explanation

A) Administering oxygen via nasal cannula at 2 L/min:
Oxygen therapy may be necessary for clients with COPD, but in this case, the primary concern is thick, tenacious bronchial secretions that the client cannot clear. Administering oxygen may be appropriate if the client has low oxygen saturation, but it does not directly address the difficulty in expectorating sputum. The focus should be on hydration and mobilization of secretions, rather than oxygen administration alone.

B) Helping the client select a low-salt diet:
While a low-salt diet is important for clients with conditions like hypertension or heart failure, it is not directly relevant to the issue of tenacious bronchial secretions in COPD. The priority in this scenario is to improve the client’s ability to clear the thick mucus, which is more effectively addressed by hydration rather than dietary changes.

C) Maintaining a semi-Fowler's position as often as possible:
Positioning the client in a semi-Fowler's position can help improve lung expansion and facilitate breathing. It can also reduce the work of breathing and increase comfort. However, while this is a helpful positioning strategy, it is not the most direct intervention to address the client’s difficulty with expectoration. The client’s difficulty with mucus clearance is best addressed with hydration to thin the secretions.

D) Encouraging the client to drink 2 to 3 L of water daily:
Hydration is one of the most important interventions for clients with COPD who have tenacious bronchial secretions. Adequate fluid intake helps to thin mucus, making it easier to cough up and clear from the airways. This intervention directly addresses the client’s complaint of not being able to bring up mucus, making it the most appropriate action to take.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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