A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?

Increase the client's oxygen to 6 liters/minute.

Obtain a stat arterial blood gas.

Lower the bed to a semi-Fowler's position.

Encourage the client to use pursed-lip breathing.

Answer and Explanation

The Correct Answer is B

A.   Increasing oxygen flow might seem like an immediate response, but it's crucial to be cautious with oxygen therapy in COPD patients. They often have a chronic CO2 retention issue, and excessive oxygen can sometimes reduce their drive to breathe, potentially worsening their condition. The increase in oxygen should be based on specific clinical guidelines and patient response, rather than an automatic increase.
B.   Obtaining a stat arterial blood gas (ABG) is an important diagnostic step to evaluate the client’s oxygenation, ventilation, and acid-base status. This can provide critical information on the severity of the dyspnea and guide further treatment. It’s an essential action, particularly in acute dyspnea, as it helps in understanding the underlying cause and tailoring appropriate interventions.
C.   The client is already in a high-Fowler’s position, which is optimal for improving lung expansion and easing dyspnea. Lowering the bed to a semi-Fowler’s position might not provide additional relief and could potentially worsen the client’s dyspnea. High-Fowler's position is generally preferred for severe dyspnea as it maximizes lung expansion and facilitates breathing.
D.   Pursed-lip breathing is a helpful technique for managing dyspnea in COPD patients. It helps to prolong exhalation, reduce airway collapse, and improve gas exchange. This technique can provide immediate relief by helping the client control their breathing and reduce feelings of breathlessness.

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Correct Answer is D

Explanation

A. These symptoms indicate a urinary tract issue but do not necessarily indicate a high risk for injury. While they are uncomfortable, they do not typically lead to physical harm.
B. Azotemia is the build-up of waste products in the blood, and anorexia is a loss of appetite. These symptoms indicate a more severe kidney problem and do not specifically point to an increased risk of injury due to a potential UTI.
C. These symptoms suggest kidney involvement but do not necessarily indicate an imminent risk of injury. While they are important to address, they do not warrant the nursing problem of "high risk for injury due to potential urinary tract infection."

D. Fever and dysuria are classic symptoms of a urinary tract infection (UTI). A UTI can progress to a more serious infection, such as pyelonephritis, which can lead to sepsis and potentially life-threatening complications. Therefore, these symptoms indicate a high risk for injury due to the potential for a UTI to worsen.

A. Minimize intake of spicy foods. B. Remain upright following meals. C. Avoid wearing tight fitting clothes. D. Begin a smoking cessation program.

Correct Answer is B

Explanation

A. Spicy foods can exacerbate GERD symptoms by irritating the esophagus and increasing acid production. While minimizing spicy foods is important, it is one of several dietary changes that can help manage GERD. It’s beneficial but may not be the single most critical instruction compared to other lifestyle modifications.
B. Remaining upright after meals is crucial for managing GERD. Lying down or reclining too soon after eating can allow stomach acid to flow back into the esophagus, worsening symptoms. Staying upright helps to facilitate digestion and reduce acid reflux, making this practice highly important for symptom control and prevention of reflux.
C. Tight-fitting clothes can increase abdominal pressure, which may contribute to the occurrence of acid reflux. While this is a helpful instruction to prevent exacerbation of symptoms, it may not be as directly impactful as remaining upright after meals.
D. Smoking can weaken the lower esophageal sphincter (LES), making it easier for stomach acid to reflux into the esophagus. However, while important, this instruction might be considered a secondary priority compared to immediate practical strategies like maintaining an upright position after eating.

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A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating a client's symptoms, and formulates the nursing problem, "High risk for injury due to potential urinary tract infection." Which symptoms indicate the need for this nursing problem?

Correct Answer is D

Explanation

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

Correct Answer is B

Explanation

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Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.