The nurse is planning the care of a client diagnosed with emphysema. The client is not currently reporting increased dyspnea, but the nurse has noted the client is anxious. Which nursing intervention(s) should be implemented?

Administer their inhaler medications and increase the oxygen.

Notify the physician and administer lorazepam.

Dim the lights and encourage the client to take a nap.

Sit with the client and provide comfort measures.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Administering inhaler medications and increasing oxygen may be necessary if the client is experiencing respiratory distress. However, since the client is not currently reporting increased dyspnea, this intervention is not immediately required. The focus should be on addressing the client’s anxiety.

Choice B reason:

Notifying the physician and administering lorazepam may be appropriate if the client’s anxiety is severe and not manageable through non-pharmacological means. However, it is generally best to try comfort measures and non-pharmacological interventions first.

Choice C reason:

Dimming the lights and encouraging the client to take a nap can help reduce anxiety, but it may not be the most effective initial intervention. Providing direct comfort and reassurance is often more beneficial in addressing immediate anxiety.

Choice D reason:

Sitting with the client and providing comfort measures is the most appropriate intervention. This approach helps to alleviate anxiety through direct support and reassurance. Techniques such as deep breathing exercises, talking calmly, and providing a comforting presence can significantly reduce anxiety.

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Correct Answer is D

Explanation

Choice A reason: Asking if the client would like to see a member of the clergy to receive a blessing can be supportive, but it may not directly address the client’s immediate emotional needs. While spiritual support is important, the nurse should first focus on the client’s expressed concerns about their wife.

Choice B reason: Inquiring if the client has children who can help their wife is practical, but it may not address the client’s emotional distress. The nurse should prioritize providing emotional support and facilitating communication between the client and their family.

Choice C reason: Asking if the client has a living will is important for end-of-life planning, but it does not directly address the client’s emotional concerns. This question is more appropriate for a discussion about advance directives rather than an immediate response to the client’s expressed worries

Choice D reason: Encouraging the client to discuss their feelings with their wife is the most appropriate response. It addresses the client’s emotional needs and promotes open communication between the client and their spouse. This can help alleviate some of the client’s anxiety and ensure that their wife is aware of their feelings and concerns.

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 is planning the care of a client diagnosed with emphysema. The client is not currently reporting increased dyspnea, but the nurse has noted the client is anxious. Which nursing intervention(s) should be implemented?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is in the end stage of chronic bronchitis tells the nurse, “I don’t know how my wife will manage without me.” The most appropriate response by the nurse at this time is:

Correct Answer is D

Explanation

Which is the best method for the nurse to correctly identify a client prior to surgery?

Correct Answer is C

Explanation

Which of the following postoperative patients is at greatest risk for respiratory complications?

A nurse is assessing a newly admitted client whose chief complaint is “coughing up blood” and whose recent history includes a productive cough and night sweats. What is the nurse’s priority intervention?

A client in the beginning stages of an asthma attack has arterial blood gases that reveal the following results: pH 7.51, PaCO2 28 mmHg, PaO2 75 mmHg, O2 saturation 92%, HCO3 24 mEq/L. The nurse interprets this blood gas result as:

The nurse prioritizes impaired gas exchange as a problem for a client with an asthma exacerbation. Which of the following is the client’s priority goal?

The nurse is planning the care of a client diagnosed with emphysema. The client is not currently reporting increased dyspnea, but the nurse has noted the client is anxious. Which nursing intervention(s) should be implemented?

The nurse is aware that the client who is prescribed medications for tuberculosis should have which laboratory test(s) assessed monthly?

The experienced nurse understands that the student nurse may require additional instruction regarding proper respiratory assessment techniques when the nurse observes the student: (SELECT ALL THAT APPLY)

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?