A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

Encourage the client to take breaks from oxygen use to prevent tolerance.

Maintain nasal oxygen at a 1 to 2 liter/minute flow rate.

Assess cheeks and posterior ears for signs of skin breakdown.

Teach the client how to safely increase oxygen flow when they deem necessary.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While it is important to monitor oxygen use to prevent hypoxia and hypercapnia, taking breaks from oxygen use is not typically recommended for clients with COPD. These clients often require supplemental oxygen to maintain adequate oxygen saturation.
Choice B rationale
Maintaining a low flow rate of oxygen is crucial in clients with COPD. These clients are often “CO2 retainers,” and administering a high concentration of oxygen can suppress their respiratory drive, leading to further CO2 retention and respiratory distress.
Choice C rationale
While it is important to assess for signs of skin breakdown in clients receiving oxygen therapy, this is not the priority when administering nasal oxygen to a client with COPD38.
Choice D rationale
Clients should not adjust their oxygen flow rate without medical supervision. Increasing the oxygen flow rate can lead to hyperoxia, which can be harmful, especially in clients with COPD who are CO2 retainers.

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Correct Answer is A

Explanation

Choice A rationale
The initial assessment finding in a client diagnosed with a pulmonary embolism (PE) is typically dyspnea and anxiety. This is because a PE can block blood flow in the lungs, leading to difficulty breathing (dyspnea). The sudden onset of this symptom can cause significant anxiety in the patient.
Choice B rationale
An altered level of consciousness is not typically an initial finding in PE. While severe cases can lead to decreased oxygen levels in the blood, causing confusion or loss of consciousness, these are not usually initial symptoms.
Choice C rationale
Wheezing in lung bases is not a typical initial finding in PE. Wheezing is more commonly associated with conditions that cause narrowing of the airways, such as asthma or COPD12.
Choice D rationale
While an increased pulse and respiratory rate can occur in PE due to the body’s attempt to compensate for decreased oxygen in the blood, they are not the most specific initial findings. Dyspnea and anxiety are more characteristic initial symptoms of PE12.

A. “You will not be able to eat breakfast until after you are washed.”. B. “Please tell me what is worrying you at this time.”. C. “I am going to wash you now and then you will take your medications.”. D. “Why are you crying again? We haven’t touched you yet.”.

Correct Answer is B

Explanation

Choice A rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice B rationale
This response is the most appropriate as it acknowledges the patient’s emotional state and opens up a dialogue for the patient to express their worries or concerns. By asking the patient what is worrying them, the nurse shows empathy and provides an opportunity for the patient to voice their fears or concerns, which can be the first step towards resolving the issue.
Choice C rationale
This response is not appropriate as it does not address the patient’s emotional state and may come across as dismissive or coercive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.
Choice D rationale
This response is not appropriate as it may come across as dismissive or insensitive. It is important to approach a tearful and refusing patient with empathy and understanding, acknowledging their feelings and concerns.

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A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client newly diagnosed with a pulmonary embolism (PE). Which of the following is the initial assessment finding in the client diagnosed with PE?

Correct Answer is A

Explanation

A nurse is caring for a patient who is tearful while refusing care and medications. Which of the following is the most appropriate response by the nurse?

Correct Answer is B

Explanation

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