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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Increased JVD and pedal edema indicate fluid overload in heart failure, where reduced cardiac output causes venous congestion. Assessing breathing for dyspnea or crackles detects pulmonary edema, as fluid backs into alveoli, impairing gas exchange. This urgent finding guides interventions like diuretics, critical before reporting.

Choice B reason: Palpating pedal pulses assesses arterial flow, not fluid overload causing JVD and edema, which are venous issues in heart failure. Pulses may be normal despite congestion. Breathing changes indicate pulmonary edema, a life-threatening complication, making this assessment more critical for detecting acute decompensation.

Choice C reason: Assessing calf inflammation may detect thrombosis, a heart failure risk, but JVD and edema suggest fluid overload, not clotting. Breathing changes are more urgent, indicating pulmonary edema from alveolar fluid, requiring immediate intervention to prevent respiratory failure, unlike inflammation, which is less immediate.

Choice D reason: Inspecting peripheral vein distention confirms venous congestion but is less critical than breathing assessment. In heart failure, fluid overload risks pulmonary edema, where alveolar fluid causes dyspnea. Monitoring breathing detects this severe complication, prioritizing intervention to ensure oxygenation over additional venous assessment.

A. Discontinue the use of the nasal cannula. B. Decrease the flow rate to 1 L/minute. C. Apply lubricant to the cannula tubing. D. Place padding around the cannula tubing.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with heart failure is receiving intravenous fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider?

Correct Answer is A

Explanation

After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen per nasal cannula at 3 L/minute, the nurse observes a red macular rash developing on the client’s right cheek. Which intervention should the nurse implement?

Correct Answer is D

Explanation

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