The nurse has applied a client problem of ineffective gas exchange for a client diagnosed with chronic bronchitis. Which intervention would the nurse include in the plan of care?

Administer oxygen per prescriber’s order to keep SpO2 greater than 96%.

Place patient in Sims position to assist with airway clearance.

Assess client use of a peak expiratory flow rate meter.

Assist with coughing and deep breathing at least every 2 hours while awake.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Administering oxygen per the prescriber’s order to keep SpO2 greater than 96% is not typically recommended for clients with chronic bronchitis. High levels of oxygen can suppress the respiratory drive in clients with chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis. The target SpO2 for these clients is usually between 88% and 92%.

Choice B reason:

Placing the patient in the Sims position is not the most effective position for airway clearance. The Fowler’s or semi-Fowler’s position is generally preferred as it promotes better lung expansion and facilitates easier breathing.

Choice C reason:

Assessing the client’s use of a peak expiratory flow rate meter is important for monitoring the severity of bronchospasm and airflow obstruction. However, it is not a direct intervention for improving gas exchange.

Choice D reason:

Assisting with coughing and deep breathing at least every 2 hours while awake is an effective intervention for clients with chronic bronchitis. This helps to mobilize secretions, improve ventilation, and enhance gas exchange. Regular coughing and deep breathing exercises can prevent atelectasis and reduce the risk of respiratory infections.

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Correct Answer is B

Explanation

Choice A Reason:

Increasing the client’s intake of Vitamin C can help with wound healing due to its role in collagen formation. However, this is not an immediate action to prevent wound dehiscence. While important for overall recovery, it does not directly address the mechanical stress on the incision site that can lead to dehiscence.

Choice B Reason:

Teaching the client to splint the incision when coughing is the most effective immediate action to prevent wound dehiscence. Splinting provides support to the incision site, reducing the risk of the wound opening due to the pressure exerted during coughing or other activities that increase intra-abdominal pressure. This method directly addresses the mechanical stress that can cause dehiscence.

Choice C Reason:

Having the client do abdominal exercises is not appropriate in the immediate postoperative period as it can increase the risk of wound dehiscence. Abdominal exercises can put additional strain on the incision site, potentially leading to separation of the wound edges.

Choice D Reason:

Performing passive range of motion exercises is beneficial for preventing complications such as joint stiffness and muscle atrophy. However, it does not specifically address the prevention of wound dehiscence. These exercises do not provide the necessary support to the incision site to prevent it from opening.

A. Reduces rebreathing of exhaled air. B. Delivers high percentages of oxygen at flow rates of 10 to 15 L/min. C. Provides a precise amount of oxygen. D. Works independently of client breathing factors and flow of oxygen.

Correct Answer is C

Explanation

Choice A reason:

Reducing rebreathing of exhaled air is not a primary characteristic of a Venturi mask. This feature is more associated with non-rebreather masks, which have a one-way valve to prevent exhaled air from being inhaled again.

Choice B reason:

Delivering high percentages of oxygen at flow rates of 10 to 15 L/min is not specific to Venturi masks. Non-rebreather masks are typically used for high oxygen flow rates. Venturi masks are designed to deliver precise oxygen concentrations at lower flow rates.

Choice C reason:

Providing a precise amount of oxygen is the key characteristic of a Venturi mask. Venturi masks are equipped with color-coded adapters that allow for the delivery of specific oxygen concentrations, regardless of the patient’s breathing pattern.

Choice D reason:

Working independently of client breathing factors and flow of oxygen is not entirely accurate. While Venturi masks do provide a consistent oxygen concentration, they still depend on the flow of oxygen set by the healthcare provider.

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The nurse has applied a client problem of ineffective gas exchange for a client diagnosed with chronic bronchitis. Which intervention would the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing action should the nurse implement to prevent wound dehiscence in the postoperative client?

Correct Answer is B

Explanation

Which of the following is a characteristic of a Venturi mask?

Correct Answer is C

Explanation

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