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 C
Explanation
A. Evaluating upper and lower extremities for perfusion, pulse volume, and pitting edema is important in assessing peripheral perfusion, but the priority action in this scenario is to initiate treatment for a suspected myocardial infarction.
B. Placing an indwelling urinary catheter and instituting strict intake and output measurements is not the priority action in this scenario. The client's symptoms and history suggest a cardiac event requiring immediate intervention.
C. Administering four 81 mg aspirin tablets (324 mg total) as soon as possible is the priority action for a client presenting with chest pain suggestive of acute coronary syndrome. Aspirin helps to prevent platelet aggregation and reduce the risk of clot formation.
D. Securing client consent for coronary angiography and percutaneous coronary intervention may be necessary but is not the immediate priority. The client needs immediate treatment to alleviate symptoms and stabilize the condition.
Correct Answer is A
Explanation
A. Hydrocortisone: In Addison's disease, there is adrenal insufficiency leading to decreased cortisol production. During times of stress or illness, such as in this case of an acute viral infection, cortisol replacement therapy (such as hydrocortisone) is crucial to supplement the deficient endogenous cortisol production. This helps to manage the client's weakened state and stabilize their condition.
B. Potassium chloride: While the client's potassium level is elevated, indicating hyperkalemia, administering potassium chloride intravenously would exacerbate the hyperkalemia and potentially lead to further complications, such as cardiac arrhythmias.
C. Regular insulin: Regular insulin is indicated for the treatment of hyperglycemia, but the client's glucose level is low, indicating hypoglycemia. Administering regular insulin in this scenario would further decrease the client's blood glucose level, worsening their condition.
D. Broad spectrum antibiotic: While an acute viral infection may predispose the client to secondary bacterial infections, there is no indication from the client's presentation or laboratory values suggesting a need for broad spectrum antibiotics at this time. The priority is addressing
the adrenal crisis and stabilizing the client's condition with appropriate cortisol replacement therapy.
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