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 B

Explanation

Choice A reason: Lung sounds being clear bilaterally, both anterior and posterior, is a positive sign and indicates that there are no immediate obstructions or significant inflammation in the airways. However, it does not provide a comprehensive measure of asthma control over time. Asthma control is better assessed through objective measures like peak expiratory flow rate (PEFR) readings.

Choice B reason: Peak expiratory flow rate (PEFR) readings in the green zone indicate that the client’s asthma is well-controlled. The green zone typically represents 80-100% of the client’s personal best PEFR, suggesting that their airways are open and they are not experiencing significant bronchoconstriction. Regular monitoring of PEFR helps in assessing the effectiveness of the asthma management plan and making necessary adjustments to prevent exacerbations.

Choice C reason: Reporting shortness of breath when engaging in exercise suggests that the client’s asthma may not be fully controlled. Exercise-induced bronchoconstriction is a common issue in asthma, and experiencing symptoms during physical activity indicates that the current medication regimen may need adjustment.

Choice D reason: Having three occurrences of asthma exacerbations in the past month indicates poor asthma control. Frequent exacerbations suggest that the client’s asthma is not well-managed and that their medication regimen may need to be reviewed and adjusted.

A. Administer oxygen per prescriber’s order to keep SpO2 greater than 96%. B. Place patient in Sims position to assist with airway clearance. C. Assess client use of a peak expiratory flow rate meter. D. Assist with coughing and deep breathing at least every 2 hours while awake.

Correct Answer is D

Explanation

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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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

The nurse recognizes the assessment data which best indicates that the client diagnosed with asthma is achieving good control with the prescribed medication regimen is when:

Correct Answer is B

Explanation

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?

Correct Answer is D

Explanation

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