A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.
The client tells the nurse she has been having difficulty breathing.
Which of the following actions is the nurse's priority at this time?

Have the client cough and expectorate secretions.

Instruct the client to use a pursed-lip breathing technique.

Increase the oxygen flow to 3 L/min.

Evaluate the client's respiratory status.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Having the client cough and expectorate secretions is a reasonable intervention for managing respiratory distress, but it is not the top priority. The nurse should first assess the client's overall respiratory status to determine the severity of the problem.

Choice B rationale:

Instructing the client to use a pursed-lip breathing technique is a helpful strategy to improve breathing in some cases. However, it should not be the top priority when a client is experiencing difficulty breathing. Assessment should come first.

Choice C rationale:

Increasing the oxygen flow to 3 L/min without a proper assessment is not advisable. It's essential to evaluate the client's respiratory status before making any adjustments to the oxygen therapy.

Choice D rationale:

"Evaluate the client's respiratory status" is the correct response. When a client with COPD and oxygen therapy reports difficulty breathing, the nurse's priority is to assess the client's respiratory status. This assessment will help determine the cause of the breathing difficulty and guide appropriate interventions. The nurse should also check the oxygen saturation levels, respiratory rate, and auscultate lung sounds to assess the severity of the issue.

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Correct Answer is A

Explanation

The correct answer is choiceA. Heart rate 50/min.

Choice A rationale:

Atenolol is a beta-blocker that can significantly lower heart rate.A heart rate of 50/min is considered bradycardia (slow heart rate), and administering atenolol could further decrease the heart rate to a dangerously low level. Therefore, the nurse should withhold the medication in this case.

Choice B rationale:

A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not contraindicate the use of atenolol. Therefore, this finding would not require withholding the medication.

Choice C rationale:

An oxygen saturation of 95% is within the normal range (typically 95-100%) and does not contraindicate the use of atenolol. Thus, this finding would not necessitate withholding the medication.

Choice D rationale:

While a blood pressure of 160/94 mm Hg indicates hypertension, atenolol is often prescribed to manage high blood pressure. Therefore, this finding would not require withholding the medication.

A. Eat foods that contain plenty of potassium. B. Take the medication at bedtime. C. Take aspirin for headaches. D. Expect some swelling in the hands and feet.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should instruct the client to consume foods rich in potassium because furosemide, a loop diuretic, can lead to potassium depletion. By consuming potassium-rich foods, the client can help maintain proper electrolyte balance. Common potassium-rich foods include bananas, oranges, potatoes, and leafy greens. It is crucial to prevent hypokalemia, as it can result in adverse effects such as cardiac dysrhythmias and muscle weakness.

Choice B rationale:

Taking furosemide at bedtime is not necessary, and it is not a standard instruction. Furosemide is usually taken in the morning to avoid nocturia, as it increases urine output. This option does not address the primary concern of managing pulmonary edema and the potential electrolyte imbalances associated with furosemide use.

Choice C rationale:

Taking aspirin for headaches is not relevant to the client's condition of pulmonary edema or the use of furosemide. This choice does not provide valuable guidance to the client and may lead to unnecessary medication use.

Choice D rationale:

Expecting swelling in the hands and feet is not an appropriate instruction for a client with pulmonary edema. The goal of furosemide therapy is to reduce edema and fluid retention, not to expect or tolerate swelling. This option does not contribute to the client's well-being and recovery.

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A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.The client tells the nurse she has been having difficulty breathing.Which of the following actions is the nurse's priority at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client prior to administering atenolol. For which of the following findings should the nurse withhold the medication?

Correct Answer is A

Explanation

A nurse is reinforcing discharge teaching with a client who has pulmonary edema and is about to start taking furosemide.Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.
The client tells the nurse she has been having difficulty breathing.
Which of the following actions is the nurse's priority at this time?