The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?
Patient will exhibit O2 saturation > 92% by discharge.
Teach pursed-lip breathing prior to discharge.
Patient will state 2 ways to decrease chance of reinfection by the end of shift.
Patient will demonstrate pursed-lip breathing.
The Correct Answer is C
This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.
Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.
The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.
Choice B is wrong because it is not a goal statement, but an intervention.
A goal statement should describe the expected outcome of the intervention, not the intervention itself.
Choice D is wrong because it is not measurable or time-bound.
A goal statement should have a clear indicator of how and when the outcome will be achieved.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse has a duty to protect the patient’s rights and well-being, and to report any signs of abuse or neglect. Financial abuse is defined as someone illegally or improperly using an elder’s money or belongings for their own personal use. It is a common form of elder abuse and can have serious consequences for the victim’s physical and mental health.
The nurse should not assume that the son has the patient’s best interest in mind (choice A), as this may not be the case.
The nurse should not ignore the situation or dismiss it as a non-clinical issue (choice B), as this would violate the nurse’s ethical and legal obligations. The nurse should not notify the primary care physician that the patient can no longer care for himself (choice C), as this may not be true and may infringe on the patient’s autonomy and dignity.
The nurse should respect the patient’s wishes and help him to exercise his rights and choices.
The nurse should also provide support and resources to the patient, such as counselling, legal aid, or social services.
Correct Answer is C
Explanation
A patient with a BMI of 38 is considered to have obesity, which means they have excess body fat that may impair their mobility and increase their risk of complications such as pressure ulcers, infections, and respiratory problems. A bariatric bed is designed to accommodate the weight and size of obese patients, and a trapeze bar can help them change positions and transfer to a chair or wheelchair.
These interventions can promote comfort, safety, and independence for the patient.
Choice A is wrong because hourly vital signs are not necessary for a patient with obesity unless they have other conditions that warrant frequent monitoring.
Choice B is wrong because implementing all fall risk precautions may be excessive and restrictive for a patient with obesity who is otherwise stable and alert.
Choice D is wrong because supine positioning can compromise the patient’s breathing and circulation, and increase the risk of pressure ulcers and aspiration.
The patient should be encouraged to change positions frequently and elevate the head of the bed when lying down.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.