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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Ambulation is a general measure that can help improve overall lung function by promoting deep breathing, coughing, and mobilization of secretions. However, it is not the primary measure to prevent atelectasis.
Choice B rationale
Oxygen therapy is used to treat hypoxia, which can be a result of atelectasis. However, it does not directly prevent the development of atelectasis.
Choice C rationale
Incentive spirometry is a first-line measure to prevent atelectasis. It encourages deep breathing, which helps keep the alveoli inflated and can prevent them from collapsing, thus preventing atelectasis.
Choice D rationale
Increasing oral fluid intake can help to thin secretions, making them easier to mobilize. However, it is not the primary measure to prevent atelectasis.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Viral pharyngitis can sometimes lead to serious complications such as peritonsillar abscess. Symptoms of this condition include drooling and inability to fully open the mouth. Therefore, patients should be advised to contact a healthcare provider immediately if they experience these symptoms.
Choice B rationale
Viral pharyngitis is contagious and can be spread through saliva. Therefore, patients should be advised to avoid sharing drinks or eating utensils with others to prevent the spread of the infection.
Choice C rationale
Antibiotics are not effective against viral infections, including viral pharyngitis. Therefore, taking prescribed antibiotics on time and not missing doses is not relevant in the context of viral pharyngitis.
Choice D rationale
Checking the body for skin rash twice daily is not typically necessary for patients with viral pharyngitis. While some viruses can cause a rash, it is not a common symptom of viral pharyngitis.
Choice E rationale
Drinking at least 2-3 liters of fluid per day unless contraindicated can help soothe a sore throat and prevent dehydration, which can occur if the patient has a fever or is not eating well due to the sore throat.
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