The nurse provides care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). The patient's pulse oximetry is 93% on room air with a current respiratory rate of 35 breaths per minute. The most recent chest x-ray indicates a flattened diaphragm with infiltrates. The patient is currently febrile with an increased number of white blood cells (WBCs) noted on the latest complete blood count (CBC). Which order does the nurse question for this patient based on the current data?
Chest physiotherapy (CPT) every 4 hours while awake
Oxygen therapy via nasal cannula at 3 to 4 L/min
Add humidification to the oxygen source
Raise the head of the patient's bed
The Correct Answer is A
A. Chest physiotherapy (CPT) every 4 hours while awake. CPT is used to mobilize secretions but may be too aggressive for a patient with infiltrates and respiratory distress, as it can increase fatigue and worsen respiratory status.
B. Oxygen therapy via nasal cannula at 3 to 4 L/min. Low-flow oxygen therapy is often used in COPD to prevent hypoxemia while avoiding CO₂ retention.
C. Add humidification to the oxygen source. Humidified oxygen helps prevent airway dryness and improves secretion clearance, which is beneficial for COPD patients.
D. Raise the head of the patient's bed. Elevating the head of the bed promotes lung expansion and improves oxygenation, making this an appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Polyuria: COPD with chronic respiratory acidosis is not associated with excessive urine production. Instead, clients may experience fluid retention due to right-sided heart failure (cor pulmonale).
B. Delirium: Chronic respiratory acidosis leads to CO₂ retention, which can cause confusion, drowsiness, and even delirium due to cerebral vasodilation and altered mental status.
C. Osteoporosis: While COPD patients may have osteoporosis due to steroid use or inactivity, it is not a direct effect of chronic respiratory acidosis.
D. Anxiety and depression: While common in COPD due to lifestyle limitations, anxiety and depression are not direct physiological effects of respiratory acidosis.
Correct Answer is B
Explanation
A. Nonrebreather mask. A nonrebreather mask delivers high concentrations of oxygen but requires a tight seal around the face, which is not suitable for patients with facial trauma.
B. Face tent. A face tent is the best option for a patient with facial trauma as it provides high-flow oxygen without requiring direct contact with the face, preventing pressure on injured areas.
C. Nasal cannula. A nasal cannula provides low-flow oxygen and may be ineffective for a patient requiring high-flow therapy.
D. Venturi mask. A Venturi mask delivers precise oxygen concentrations but still requires a snug fit on the face, which may not be comfortable or feasible for a patient with facial trauma.
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