The client is admitted with chronic obstructive pulmonary disease and congestive heart failure. He is receiving 2 liters of oxygen via nasal cannula with an oxygen saturation of 89%. The nurse assesses the client who is watching TV and resting comfortably. Identify the nurse’s next appropriate action.
Increase the oxygen level
Administer PRN furosemide
Deliver PRN albuterol
Continue to monitor
The Correct Answer is D
Choice A reason: Increasing the oxygen level may seem appropriate because the saturation is 89%, but in clients with COPD, oxygen therapy must be carefully titrated. These patients rely on hypoxic drive to stimulate breathing, and excessive oxygen can suppress respiratory drive, leading to CO2 retention and respiratory failure. Since the client is resting comfortably and not in distress, increasing oxygen is not the immediate action.
Choice B reason: Administering PRN furosemide is indicated for fluid overload in congestive heart failure, typically when there are signs such as pulmonary edema, crackles, or dyspnea. In this case, the client is resting comfortably without evidence of acute fluid overload, so furosemide is not warranted.
Choice C reason: Delivering PRN albuterol is appropriate for acute bronchospasm or wheezing. The client is not showing signs of respiratory distress, wheezing, or bronchospasm. Therefore, albuterol is not necessary at this time.
Choice D reason: Continuing to monitor is the most appropriate action. The client’s oxygen saturation of 89% is acceptable for a COPD patient, as their target range is often 88–92%. Since the client is comfortable and stable, the nurse should continue monitoring while avoiding unnecessary interventions that could destabilize the patient’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Telling a new nurse that they will learn to deal with moral distress does not promote a healthy work environment. While moral distress is a reality in nursing, this statement normalizes distress rather than teaching strategies to prevent or address it. It can discourage the new nurse and foster a negative outlook.
Choice B reason: Suggesting that all nurses will experience bullying is harmful and perpetuates a toxic culture. This statement does not encourage proactive measures to prevent bullying or promote respect. Instead, it normalizes unacceptable behavior, which undermines the principles of a healthy workplace.
Choice C reason: Advising a nurse to get another job if they don’t feel supported is dismissive and unhelpful. It does not encourage collaboration, communication, or advocacy for change within the workplace. A healthy environment is built through constructive actions, not avoidance.
Choice D reason: Reporting workplace injuries to the manager is a constructive and appropriate statement. It emphasizes accountability, safety, and communication. This action ensures that hazards are addressed, promotes transparency, and protects both staff and clients. It is a positive behavior that supports a healthy work environment.
Correct Answer is B
Explanation
Choice A reason: Providing instructions about diet requires teaching, which is outside the scope of practice for an LPN/LVN. Teaching is a responsibility reserved for registered nurses because it involves assessment, evaluation, and patient education.
Choice B reason: Administering oxandrolone 5 mg/day is appropriate for an LPN/LVN. Medication administration is within their scope of practice, provided the medication is prescribed and the nurse follows established protocols. This task does not require independent judgment or advanced assessment skills.
Choice C reason: Assessing for nutritional risk factors requires critical thinking and advanced assessment skills, which are responsibilities of the RN. LPNs/LVNs can collect data but cannot independently interpret or evaluate risk factors.
Choice D reason: Developing a plan of care is a complex responsibility that involves synthesizing assessment data, prioritizing needs, and setting goals. This is outside the scope of practice for LPNs/LVNs and must be completed by an RN.
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