A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula, is currently short of breath. Which action should the nurse take?
Have the client breathe into a paper bag.
Ask the client to take short, rapid breaths.
Instruct the client in pursed lip breathing.
Increase oxygen to three L/minute.
The Correct Answer is C
A. Having the client breathe into a paper bag is a technique sometimes used for anxiety-induced hyperventilation but is not appropriate for a client with chronic obstructive lung disease
experiencing shortness of breath. It can lead to a buildup of carbon dioxide, worsening the client's condition.
B. Asking the client to take short, rapid breaths may exacerbate hyperventilation and increase the client's anxiety. This breathing pattern can lead to further respiratory distress in a client with
chronic obstructive lung disease.
C. Instructing the client in pursed lip breathing is the most appropriate action. Pursed lip breathing helps to prolong exhalation, reduce air trapping, and improve gas exchange in clients with chronic obstructive lung disease. It can help alleviate shortness of breath and promote
relaxation.
D. Increasing oxygen to three L/minute may not be necessary and could potentially lead to oxygen toxicity. The priority is to help the client manage their shortness of breath effectively through breathing techniques.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Blood urea nitrogen (BUN) is not typically monitored to evaluate the effectiveness of antibiotics in treating respiratory tract infections. It is more commonly monitored to assess renal function and hydration status.
B. White blood cell (WBC count is monitored to evaluate the body's response to infection and the effectiveness of antibiotic therapy. A decrease in the WBC count can indicate resolution of the infection.
C. Red blood cell (RBC count is not directly related to the evaluation of antibiotic effectiveness in treating respiratory tract infections.
D. Urinalysis is not typically monitored to evaluate the effectiveness of antibiotics in treating respiratory tract infections unless there are specific indications of urinary tract involvement.
E. Sputum culture and sensitivity testing is important to identify the causative organism of the respiratory tract infection and determine its susceptibility to antibiotics. Monitoring the results of sputum culture and sensitivity helps ensure appropriate antibiotic selection.
F. Serum potassium levels may be monitored for clients receiving certain antibiotics, such as some types of penicillins or fluoroquinolones, due to the potential for electrolyte disturbances.
However, it is not a direct measure of antibiotic effectiveness in treating respiratory tract infections.
Correct Answer is B
Explanation
A. Record the client's intake and output every shift: While important for monitoring fluid balance, this intervention does not directly facilitate increased fluid intake.
B. Offer a glass of fluid every hour while awake: This intervention ensures regular and frequent opportunities for the resident to consume fluids, which can help increase overall intake.
C. Increase fluids provided with the client's meals: While this may help increase fluid intake, relying solely on meals may not be sufficient, especially if the resident does not finish their meals.
D. Maintain a full pitcher of water at the bedside: While having water readily available is important, relying solely on this may not ensure regular intake throughout the day.
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