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 C
Explanation
A. Weight loss: Antipsychotics are more commonly associated with weight gain, particularly atypical antipsychotics like olanzapine and clozapine.
B. Headache: While headaches may occur, they are not among the most common side effects of antipsychotics.
C. Dry mouth: Antipsychotics often cause dry mouth due to their anticholinergic effects. Other anticholinergic side effects include constipation and blurred vision.
D. Insomnia: Antipsychotics are more likely to cause sedation rather than insomnia, particularly first-generation agents like chlorpromazine.
Correct Answer is B
Explanation
A. Restricts the client's ability to eat, speak, or drink: Unlike a mask, a nasal cannula allows the client to eat, drink, and speak freely.
B. Delivers a low concentration of oxygen: A nasal cannula delivers a low oxygen concentration (24%-44%) at flow rates of 1-6 L/min.
C. Delivers a constant rate of a specific concentration of oxygen: Oxygen concentration varies depending on the client's breathing pattern with a nasal cannula, making it not a fixed concentration delivery system.
D. Delivers a high concentration of oxygen: High-flow oxygen delivery systems like a non-rebreather mask or Venturi mask are needed for high oxygen concentrations.
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