A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse positions the client in the orthopneic position. What is the primary reason for the use of this position for this client?
Prevents pressure ulcers.
Supports hip extension.
Facilitates breathing.
Promotes urinary elimination.
The Correct Answer is C
Choice A Reason:
“Prevents pressure ulcers” is incorrect. While positioning can help prevent pressure ulcers, the orthopneic position is specifically used to aid in breathing rather than to prevent pressure ulcers. Pressure ulcers are typically managed by regularly repositioning the client and using pressure-relieving devices.
Choice B Reason:
“Supports hip extension” is incorrect. The orthopneic position does not primarily support hip extension. This position involves sitting up and leaning forward, which does not significantly affect the hips.
Choice C Reason:
“Facilitates breathing” is correct. The orthopneic position, also known as the tripod position, helps to improve breathing in clients with COPD. By leaning forward and resting the arms on a table or knees, the diaphragm can move more freely, and accessory muscles of respiration are better utilized, reducing the work of breathing.
Choice D Reason:
“Promotes urinary elimination” is incorrect. The orthopneic position is not intended to promote urinary elimination. Urinary elimination is typically managed through other interventions such as ensuring adequate hydration and, if necessary, using a catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.4"]
Explanation
Step-by-Step Calculation
Step 1: Identify the desired dose and the concentration of the medication.
Desired dose = 4 mg
Concentration = 10 mg/mL
Step 2: Set up the calculation to find the volume to administer.
Volume to administer (mL) = Desired dose (mg) ÷ Concentration (mg/mL)
Step 3: Perform the division.
4 mg ÷ 10 mg/mL = 0.4 mL
Step 4: Round the answer to the nearest whole number.
0.4 mL rounded to the nearest whole number is 0 mL
Step 5: Apply the instruction to use a leading zero if it applies and do not use a trailing zero.
The final volume to administer is 0.4 mL.
Therefore, the nurse should administer 0.4 mL of furosemide via IV bolus to the client.
Correct Answer is A
Explanation
Choice A Reason:
Restlessness is often one of the earliest signs of hypoxia. When the body experiences low oxygen levels, the brain is one of the first organs to be affected. This can lead to symptoms such as anxiety, agitation, and restlessness as the brain struggles to function properly without adequate oxygen. These symptoms occur because the body is trying to compensate for the lack of oxygen by increasing respiratory and heart rates, which can make a person feel uneasy or restless.
Choice B Reason:
Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. While cyanosis is a significant indicator of hypoxia, it is typically a later sign. By the time cyanosis is visible, hypoxia has usually been present for some time, and oxygen levels have been critically low. Therefore, it is not the earliest clinical manifestation of hypoxia.
Choice C Reason:
Apnea is the absence of breathing. This is a severe and late sign of hypoxia. When a person stops breathing, it indicates that the body has been deprived of oxygen for an extended period, leading to critical conditions. Apnea is a medical emergency and requires immediate intervention, but it is not an early sign of hypoxia.
Choice D Reason:
Bradycardia is a slower than normal heart rate. Like apnea, bradycardia is a late sign of hypoxia. Initially, the body responds to low oxygen levels by increasing the heart rate (tachycardia) to pump more oxygenated blood to tissues. Bradycardia occurs when the body can no longer compensate, and the heart rate slows down, indicating severe hypoxia and impending failure of the cardiovascular system.
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