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 D
Explanation
A. Seeking a tutor for help with a challenging class: Seeking help for academic difficulties is a positive coping mechanism, not a warning sign of suicide.
B. Volunteering to serve food at a homeless shelter over the holidays: Volunteering is generally a sign of social engagement and purpose, which lowers suicide risk.
C. Making plans to go to a high school dance: Engaging in social activities is a protective factor against suicide, not a warning sign.
D. Displaying extreme mood swings: Sudden, extreme mood changes, especially from depression to euphoria, can be a warning sign of suicidal ideation.
Correct Answer is D
Explanation
A. The client has a pleasant affect: "Affect" refers to outward emotional expression, whereas "mood" is the client's internal emotional state.
B. The client appears happy with an elevated mood: The nurse should document objective data rather than interpreting the client’s emotions.
C. The client self-isolated today: While self-isolation may indicate mood disturbances, it does not directly document the client’s reported mood.
D. The client rates their mood 4 out of 10: This entry reflects the client’s subjective report using a measurable scale, making it the most accurate documentation.
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