A patient diagnosed with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is the most therapeutic?
"Your disease often makes patients lose mental status."
"Your disease will be helped if you pursed-lip breathe."
"Your disease affects both your lungs and your heart, and not enough blood is being pumped."
"Your disease doesn't send enough oxygen to your fingertips."
The Correct Answer is D
A. "Your disease often makes patients lose mental status." While severe hypoxia can cause confusion, this response does not address the reason for clubbing and lacks therapeutic communication.
B. "Your disease will be helped if you pursed-lip breathe." Pursed-lip breathing helps with air trapping and exhalation in COPD, but it does not explain clubbing of the fingers.
C. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." COPD primarily affects oxygen exchange in the lungs, not necessarily blood pumping from the heart. Clubbing is due to chronic hypoxia, not poor cardiac output.
D. "Your disease doesn't send enough oxygen to your fingertips." Chronic hypoxia in COPD leads to increased capillary growth and tissue changes, resulting in clubbing of the fingers. This response is accurate and appropriately explains the cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hold the hands higher than the elbows. Hands should be held lower than the elbows to allow water to flow from the fingertips downward, preventing contamination of clean areas by dirty water.
B. Rub hands and arms to dry. Hands should be dried by patting rather than rubbing to prevent skin irritation. Also, drying should focus on the hands first, then the wrists, and then the forearms to avoid recontamination.
C. Apply 4 to 5 mL of liquid soap to the hands. The recommended amount of liquid soap is 3 to 5 mL to effectively remove microorganisms. Using too little may not clean adequately, and using too much can make rinsing difficult.
D. Adjust the water temperature to feel hot. Water should be warm, not hot, to prevent skin irritation and dryness. Hot water can damage the skin’s natural protective barrier, increasing susceptibility to infection.
Correct Answer is C
Explanation
A. Initiate a peripheral IV: While an IV line is useful for medication administration, the patient’s pain has significantly improved with nitroglycerin. An IV may be necessary later, but it is not the next step in this scenario.
B. Administer another nitroglycerin tablet: Nitroglycerin can be repeated every 5 minutes up to 3 doses if chest pain persists or does not decrease significantly. Since the pain has improved (from 6 to 2), additional nitroglycerin is unnecessary.
C. Obtain an ECG/EKG: Even though the pain improved, unstable angina can progress to myocardial infarction. An ECG helps evaluate for ischemic changes and ensures the pain is truly resolving.
D. Call the Rapid Response Team (RRT): RRT should be called for worsening chest pain, unresponsiveness, or hemodynamic instability. Since the pain has improved, calling RRT is unnecessary.
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