A charge nurse is teaching a newly licensed nurse about caring for a client who has COPD. Which of the following instructions should the charge nurse include in the teaching?
Call the provider if you note clubbing of the client's fingernails.
Have an assistive personnel ambulate the client just before meals.
Notify me if you observe that the client has distended neck veins.
Maintain the client's oxygen saturation level above 95 percent.
The Correct Answer is C
Choice A reason: Calling the provider if you note clubbing of the client's fingernails is not an instruction the charge nurse should include in the teaching. This is an unnecessary and inappropriate action, as clubbing is a chronic and irreversible sign of hypoxia that does not require immediate intervention. The nurse should document the finding and monitor the client's respiratory status.
Choice B reason: Having an assistive personnel ambulate the client just before meals is not an instruction the charge nurse should include in the teaching. This is a harmful and contraindicated action, as ambulation can increase the client's oxygen demand and cause dyspnea and fatigue. The nurse should schedule the client's activity and rest periods around the meals and provide supplemental oxygen as prescribed.
Choice C reason: Notifying the charge nurse if you observe that the client has distended neck veins is an instruction the charge nurse should include in the teaching. This is a necessary and appropriate action, as distended neck veins can indicate right-sided heart failure, which is a complication of COPD. The nurse should report the finding and assess the client for other signs of fluid overload, such as edema, weight gain, and crackles.
Choice D reason: Maintaining the client's oxygen saturation level above 95 percent is not an instruction the charge nurse should include in the teaching. This is an unrealistic and potentially harmful goal, as clients with COPD usually have lower oxygen saturation levels due to chronic hypoxia. The nurse should maintain the client's oxygen saturation level at the prescribed range, which is typically between 88 and 92 percent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Providing coverage for the nurses' breaks is a possible action that the charge nurse can take, but it is not the first one. The charge nurse should first assess the situation and identify the factors that are preventing the nurses from taking their breaks.
Choice B reason: Reviewing facility policies for taking scheduled breaks is an important action that the charge nurse can take, but it is not the first one. The charge nurse should first communicate with the nurses and understand their perspectives and needs.
Choice C reason: Determining the reasons the nurses are not taking scheduled breaks is the first action that the charge nurse should take. This will help the charge nurse to address the root cause of the problem and provide appropriate support and guidance to the nurses.
Choice D reason: Discussing time management strategies with the nurses is a helpful action that the charge nurse can take, but it is not the first one. The charge nurse should first determine if the nurses are facing any barriers or challenges that are affecting their ability to take their breaks.
Correct Answer is B
Explanation
Choice A reason: Placing a surgical mask on the client during transfer to the unit is not an appropriate action for the nurse to take. Cutaneous anthrax is not transmitted through respiratory droplets, but through direct contact with the spores that enter the skin. A surgical mask does not protect the client or others from the infection.
Choice B reason: Preparing to administer antibiotics to the client is an appropriate action for the nurse to take. Cutaneous anthrax is caused by a bacterium called Bacillus anthracis, which can be treated with antibiotics, such as ciprofloxacin or doxycycline. Antibiotics can prevent the infection from spreading to other parts of the body and causing serious complications.
Choice C reason: Planning to administer an antiviral medication to the client is not an appropriate action for the nurse to take. Cutaneous anthrax is not caused by a virus, but by a bacterium. Antiviral medications are ineffective against bacterial infections and may cause adverse effects or interactions.
Choice D reason: Wearing an N95 respirator mask while caring for the client is not an appropriate action for the nurse to take. An N95 respirator mask is used to protect the nurse from airborne pathogens, such as tuberculosis or measles. Cutaneous anthrax is not airborne, but contact-based. The nurse should wear standard precautions, such as gloves and gown, and wash their hands thoroughly after caring for the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.