A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing.
Which of the following actions is the nurse’s priority?
Call emergency services for the client.
Increase the oxygen flow to 3 L/min.
Have the client cough and expectorate secretions.
Assess the client’s respiratory status.
The Correct Answer is D
This is the nurse’s priority because it will help determine the severity of the client’s difficulty breathing and guide the appropriate interventions. According to the Mayo Clinic, oxygen therapy for COPD is indicated when there is not enough oxygen in the blood, which can be measured by a pulse oximeter or a blood gas test. Increasing the oxygen flow without assessing the oxygen level could be harmful or ineffective. Having the client cough and expectorate secretions may help clear the airway, but it is not the first action to take. Calling emergency services may be necessary if the client’s condition is life threatening, but it should not be done before assessing the respiratory status.
Choice A is wrong because it does not address the immediate need of assessing the respiratory status and may cause unnecessary panic or delay in treatment.
Choice B is wrong because it does not follow the guidelines for oxygen therapy for COPD, which require a prescription and monitoring of oxygen levels.
Increasing the oxygen flow without assessing the oxygen level could cause oxygen toxicity or suppress the respiratory drive.
Choice C is wrong because it is not the most urgent action to take.
Having the client cough and expectorate secretions may help clear the airway, but it may also increase the work of breathing and worsen hypoxia.
Assessing the respiratory status should come first.
Normal ranges for oxygen saturation are 95% to 100% for healthy individuals and 88% to 92% for most people with COPD. Normal ranges for blood gas tests vary depending on the laboratory, but generally, normal values for arterial blood gas are: pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, PaO2 80 to 100 mm Hg, HCO3 22 to 26 mEq/L.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is a responsibility of the nurse in the process of informed consent, which is the patient’s choice to have a treatment or procedure based on their full understanding of its benefits, risks, and alternatives. The nurse should provide written materials in the client’s spoken language, when possible, and verify that the client comprehends and consents to the care and procedures.
Choice A is wrong because confirming that the client is competent to sign for the procedure is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only obtain consent when initiating care or reviewing consent before providing care ordered by another health professional.
Choice B is wrong because discussing the risks of the procedure with the client is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only inform the client about what will occur during the procedure and answer any questions they may have.
Choice D is wrong because explaining alternatives to the procedure to the client is not a responsibility of the nurse, but of the health professional who directs the care. The nurse can only inform the client about what will occur during the procedure and answer any questions they may have.
Correct Answer is C
Explanation
According to Mayo Clinic, physical therapy and exercises can improve strength, flexibility and stamina for people with fibromyalgia.
Low-impact aerobics, such as swimming or biking, are recommended as they are less likely to cause muscle soreness or injury.
Choice A is wrong because antidepressant medications can help ease the pain and fatigue associated with fibromyalgia.
They are often prescribed as part of the treatment plan.
Choice B is wrong because physical manifestations of the disease do not become progressively worse despite treatment.
Fibromyalgia is a chronic condition, but it does not damage the joints, muscles or organs.
Choice D is wrong because narcotic analgesia will not be used for long-term pain control. Opioid medications can cause significant side effects and dependence and will worsen the pain over time.
They are not recommended for fibromyalgia treatment.
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