A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

The client’s oxygen saturation level is 85%.

The client is eating less than half of meals

The client’s heart rate is 110 beats per minute.

The client is reading a book.

The client’s blood pressure is 160/90 mmHg.

Answer and Explanation

Correct Answer : A,C,E

The observation(s) by the nurse that require immediate intervention to reduce the likelihood of harm to this client are:

A. The client’s oxygen saturation level is 85%. This is a sign of hypoxemia, which can lead to tissue hypoxia, organ damage, and cardiac arrest. The nurse should administer oxygen therapy and monitor the client’s respiratory status closely.

C. The client’s heart rate is 110 beats per minute. This is a sign of tachycardia, which can indicate worsening heart failure, dehydration, infection, or anxiety. The nurse should assess the client’s fluid balance, vital signs, and symptoms and report any changes to the physician. The nurse should also administer medications as prescribed to control the heart rate and reduce the cardiac workload.

E. The client’s blood pressure is 160/90 mmHg. This is a sign of hypertension, which can increase the risk of stroke, myocardial infarction, and renal failure. The nurse should administer antihypertensive medications as prescribed and monitor the client’s blood pressure and urine output. The nurse should also educate the client on lifestyle modifications to lower blood pressure, such as reducing salt intake, exercising, and managing stress .

The other observations do not require immediate intervention, but they should be addressed as part of the comprehensive nursing care plan for the client with heart failure and COPD. These include:

B. The client is eating less than half of meals. This can indicate poor appetite, nausea, dyspnea, or fatigue, which can affect the client’s nutritional status and energy level. The nurse should encourage the client to eat small, frequent, and balanced meals that are low in sodium, fat, and cholesterol. The nurse should also provide oral hygiene and offer supplements or enteral feeding if needed .

D. The client is reading a book. This can indicate that the client is coping well with the condition and engaging in leisure activities that promote relaxation and mental health. The nurse should praise the client for this positive behavior and provide emotional support and counseling as needed. The nurse should also teach the client about the signs and symptoms of exacerbation and when to seek medical help .

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Correct Answer is B

Explanation

Choice A rationale:

Altered consciousness within the first 24 hours after injury is not indicative of a developing epidural hematoma. An epidural hematoma typically manifests as a lucid interval followed by a rapid deterioration in consciousness hours after the injury.

Choice B rationale:

Cushing reflex (increased blood pressure, bradycardia, and irregular respirations) and cerebral edema after 24 hours are characteristic signs of a developing epidural hematoma. This occurs due to the accumulation of blood between the dura mater and the skull, leading to increased intracranial pressure.

Choice C rationale:

Headache and pupillary changes 48 hours after head injury are not specific signs of an epidural hematoma. These symptoms may indicate various other neurological conditions or complications.

Choice D rationale:

Fever, nuchal rigidity, and opisthotonos within hours are suggestive of meningitis rather than an epidural hematoma. These symptoms are not typical of epidural hematomas, which primarily involve alterations in consciousness and increased intracranial pressure.

A. Instill 3 mL of normal saline before suctioning. B. Instruct the client to cough as the suction tip is removed. C. Apply a water-soluble lubricant to the catheter. D. Wear protective goggles while performing the procedure. E. Wear protective goggles while performing the procedure.

Correct Answer is D

Explanation

Choice A rationale:

Instill 3 mL of normal saline before suctioning. This choice is not appropriate for suctioning excessive drooling in a client with ALS. Instilling normal saline would introduce additional fluid into the oral cavity, potentially worsening the problem by increasing the amount of secretions. The goal of suctioning is to remove excess saliva and maintain a clear airway.

Choice B rationale:

Instruct the client to cough as the suction tip is removed. Instructing the client to cough during suctioning is not a recommended practice. It may cause discomfort and can lead to an increased risk of aspiration as the client might inhale while coughing during the procedure.

Choice C rationale:

Apply a water-soluble lubricant to the catheter. Applying a water-soluble lubricant to the suction catheter is a common practice to facilitate the passage of the catheter and minimize irritation to the client's oral tissues. While it is a helpful step, it is not the primary action that should be taken to ensure the safety of the procedure.

Choice D rationale:

Wear protective goggles while performing the procedure. This is the correct choice. When suctioning a client's oral cavity, especially when dealing with excessive drooling or secretions, it is essential for the nurse to wear protective goggles. These goggles protect the nurse's eyes from potential exposure to the client's bodily fluids, reducing the risk of infection transmission.

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A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

Nursing Test Bank

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