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 C

Explanation

Choice A reason: Avoiding more time-outs in the OR is not the primary purpose of pre-operative teaching. Time-outs are a safety protocol used in the operating room to ensure that the correct procedure is being performed on the correct patient. While pre-operative teaching can contribute to overall surgical safety, its main goal is not to reduce the number of time-outs.

Choice B reason: Understanding the informed consent is an important aspect of pre-operative teaching, but it is not the primary purpose. Informed consent ensures that the patient is aware of the risks, benefits, and alternatives to the procedure. Pre-operative teaching encompasses a broader range of information, including what to expect before, during, and after surgery.

Choice C reason: Achieving better post-operative outcomes is the primary purpose of pre-operative teaching. Educating patients about their surgery, recovery process, and self-care can significantly improve their post-operative outcomes. This includes reducing anxiety, pain, and complications, as well as shortening hospital stays and enhancing overall recovery. Pre-operative education empowers patients to take an active role in their recovery, leading to better health outcomes.

Choice D reason: Reinforcing that collaborative care is essential is a component of pre-operative teaching, but it is not the primary purpose. Collaborative care involves the coordination of various healthcare professionals to provide comprehensive care to the patient. While pre-operative teaching can highlight the importance of teamwork, its main focus is on preparing the patient for surgery and recovery.

A. Ask the client their date of birth and confirm it with the chart and name of surgery. B. Check the client’s medical record number and surgical consent form. C. Check the client’s armband and ask their name, date of birth, and site of surgery. D. Ask the client their name and social security number.

Correct Answer is C

Explanation

Choice A reason: Asking the client their date of birth and confirming it with the chart and name of surgery is a good practice, but it is not the most comprehensive method. This approach verifies only one identifier and does not ensure the correct surgical site.

Choice B reason: Checking the client’s medical record number and surgical consent form is important, but it does not involve direct interaction with the client. This method verifies the documentation but does not confirm the client’s identity through personal verification.

Choice C reason: Checking the client’s armband and asking their name, date of birth, and site of surgery is the best method. This approach uses multiple identifiers and involves direct interaction with the client, ensuring accurate identification and confirmation of the correct surgical site. The use of multiple identifiers reduces the risk of errors and enhances patient safety.

Choice D reason: Asking the client their name and social security number is another method of identification, but it is not as commonly used in clinical settings due to privacy concerns. Additionally, it does not confirm the surgical site.

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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?

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Explanation

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Explanation

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