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 D
Explanation
A. Elevating the head of the bed to a 45-degree angle is important for clients with obstructive sleep apnea (OSA to help prevent airway obstruction during sleep. However, applying the
positive airway pressure device is a more immediate and direct intervention to ensure adequate breathing.
B. Removing dentures or other oral appliances may be necessary for comfort and safety during sleep, but it's not directly related to managing obstructive sleep apnea in this scenario.
C. Lifting and locking the side rails in place is a standard safety measure in healthcare settings but does not address the client's obstructive sleep apnea or ensure adequate ventilation.
D. Applying the client's positive airway pressure (PAP) device is the most important intervention before leaving the client. The PAP device helps maintain an open airway by delivering
continuous positive airway pressure, which is crucial for managing obstructive sleep apnea and preventing complications such as apnea episodes during sleep.
Correct Answer is D
Explanation
A. Share personal values to put the client at ease: Sharing personal values may not be appropriate and could potentially alienate the client or make them feel judged.
B. Get the most difficult questions over with first: Starting with difficult questions may increase the client's defensiveness and resistance to sharing information.
C. Ask questions in a vague, non-specific format: Being vague may not elicit the necessary information and could lead to misunderstandings or incomplete responses.
D. Begin with questions that are less sensitive in nature: Starting with less sensitive questions helps build rapport and trust with the client before addressing more sensitive topics like domestic violence. It allows the client to feel more comfortable and may increase the likelihood of obtaining accurate information.
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