The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?
Ensure supplemental oxygen and respiratory medications are available at all times.
Use nasal or cough tissues followed by handwashing at all times.
Avoid large crowded areas during the colder months of the year.
Get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines.
The Correct Answer is D
Choice A reason: Ensuring oxygen and medications manages exacerbations in asthma, bronchitis, and emphysema, where airway inflammation obstructs breathing. These treat symptoms, not prevent infections. Vaccines reduce influenza and pneumococcus, major exacerbation triggers, providing specific immunity to prevent severe respiratory infections, making them a higher priority.
Choice B reason: Using tissues and handwashing reduces infection spread but is less effective than vaccines for preventing exacerbations in chronic lung diseases. Influenza and pneumococcus trigger severe bronchoconstriction or inflammation. Vaccines offer targeted protection against these pathogens, prioritizing prevention over general hygiene in high-risk clients.
Choice C reason: Avoiding crowded areas in colder months reduces viral exposure, which can exacerbate asthma or COPD via inflammation. Vaccines are more effective, providing specific immunity against influenza and pneumococcus, the most common triggers of severe exacerbations, making this less critical than vaccination for preventing respiratory complications.
Choice D reason: Annual flu and PPSV23 vaccines are critical for asthma, bronchitis, and emphysema, as these conditions increase severe infection risk. Influenza and pneumococcus trigger exacerbations via airway inflammation, risking hospitalization. Vaccines stimulate antibody production, reducing infection severity, making them the top preventive measure for chronic lung disease management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Discontinuing the nasal cannula is inappropriate, as 94% SpO₂ indicates mild hypoxemia from pneumonia, requiring oxygen to support alveolar diffusion. The rash likely results from cannula pressure, not oxygen delivery. Padding addresses the rash without compromising respiratory support, ensuring continued therapy.
Choice B reason: Decreasing to 1 L/minute may worsen hypoxemia in pneumonia, where inflamed alveoli impair gas exchange (SpO₂ 94%). The rash is from mechanical irritation, not flow rate. Padding relieves pressure, maintaining oxygen delivery to improve saturation, making flow reduction counterproductive to respiratory needs.
Choice C reason: Applying lubricant reduces friction but not pressure causing the red macular rash from prolonged cannula contact. Lubricants risk aspiration. Padding alleviates pressure points, preventing skin breakdown while maintaining oxygen for pneumonia, addressing the rash’s mechanical cause more effectively than lubrication.
Choice D reason: Placing padding around the cannula tubing relieves pressure on the cheek, preventing skin breakdown from the red macular rash. This maintains oxygen at 3 L/minute, critical for pneumonia’s hypoxemia, where inflamed alveoli reduce oxygen diffusion. Padding ensures skin integrity and respiratory support, addressing both issues effectively.
Correct Answer is C
Explanation
Choice A reason: Feeling emptiness reflects depression but is less urgent than access to firearms in suicidal ideation. Firearms indicate immediate risk, requiring safety planning. Emptiness needs therapy but not priority documentation, per suicide risk assessment and mental health nursing protocols.
Choice B reason: Monthly panic attacks are relevant but not the highest priority in suicidal ideation. Firearm access poses an immediate lethal risk, requiring urgent documentation. Panic attacks are secondary, per suicide risk assessment and psychiatric nursing care standards.
Choice C reason: Documenting firearm access is critical, as it indicates a means for suicide in a client with suicidal ideation. This prompts immediate safety interventions, like removing access, to prevent harm, per suicide risk assessment and patient safety protocols in psychiatric nursing.
Choice D reason: The daughter as a reason to live is protective but less urgent than firearm access, which poses immediate risk. Firearms require priority documentation to ensure safety. This is secondary, per suicide prevention and mental health assessment standards in nursing.
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