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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. RA often causes joint pain and stiffness, which can make it challenging to complete daily activities. Teaching the client how to set priorities and pace their activities helps them balance exertion with rest, thus reducing fatigue and improving overall function. This approach supports effective management of their condition by preventing overexertion and allowing time for recovery.
B. While rest is important for managing fatigue, strict bedrest is generally not recommended for RA patients. Prolonged bedrest can lead to muscle weakness, joint stiffness, and decreased mobility. Active management through appropriate rest and activity is usually more beneficial than complete bedrest.
C. Transferring to an assisted living center may be appropriate for some clients, but this intervention is not necessarily related to managing fatigue due to rheumatoid arthritis in the current context. This
decision would typically depend on the overall level of care needed and the client’s living situation.
D. While providing reassurance is part of supportive care, it’s important to address the specific needs and management strategies for fatigue. Simply offering assurance without practical interventions may not effectively address the client’s current symptoms or help them manage their condition in the long
term.

A. Encourage active range of motion exercises. B. Assist with ambulation in the hallway. C. Provide a bedside commode for toileting. D. Teach to sleep in a side lying position.

Correct Answer is C

Explanation

A. Range of motion exercises are important for overall mobility and prevention of complications from immobility. However, they can increase cardiac workload, especially if performed actively and without supervision.
B. Ambulation, or walking in the hallway, increases cardiac workload and can exacerbate symptoms in a client with unstable angina. This activity should be minimized or restricted until the client's condition stabilizes. The focus should be on reducing activities that put additional stress on the heart.

C. Using a bedside commode helps reduce the need for the client to walk to the bathroom, which can be physically demanding and increase cardiac workload. By minimizing the effort required for toileting, the client can avoid unnecessary physical strain.
D. Sleeping in a side-lying position is not directly related to reducing cardiac workload. The client's position during sleep generally does not have as significant an impact on cardiac workload as other interventions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 establishes a nursing problem of "Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis." Which nursing intervention should the nurse include in the plan of care for this client?

Correct Answer is A

Explanation

A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement?

An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?