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. Nothing solid by mouth for 8 to 10 hours before surgery: While some surgeries may require longer fasting, the general guideline is at least 6-8 hours for solids.
B. Nothing solid by mouth for 10 to 12 hours before surgery: This is longer than necessary based on standard preoperative fasting guidelines.
C. Nothing solid by mouth for 12 to 14 hours before surgery: This is excessive and may lead to unnecessary discomfort.
D. Nothing solid by mouth for 6 to 8 hours before surgery: General guidelines recommend NPO for at least 6-8 hours before surgery to reduce the risk of aspiration during anesthesia. Clear liquids may be allowed up to 2 hours before surgery.
Correct Answer is C
Explanation
A. Administer oxygen at 2 L/min.: Oxygen is necessary, but raising the head of the bed first can improve oxygenation more effectively and quickly.
B. Encourage coughing and deep breathing.: While effective, this should be done after positioning the patient appropriately to optimize oxygenation.
C. Raise the head of the bed.: The priority intervention for low oxygen saturation is to improve ventilation and perfusion by raising the head of the bed. This enhances lung expansion, making it easier for the patient to breathe.
D. Administer prescribed analgesic medication.: Pain management is important, but it is not the priority when oxygen levels are dangerously low.
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