A nurse is caring for a client in the emergency department.

Which of the following interventions should the nurse include in the plan of care? Select all that apply.

Place the client in a supine position.

Instruct the client to perform diaphragmatic breathing.

Increase oxygen flow rate to 4 L/min.

Assess the client's breath sounds.

Restrict the client's fluid intake.

Perform chest percussion and vibration.

Answer and Explanation

Correct Answer : B,D,F

A. Place the client in a supine position: The supine position can worsen dyspnea by limiting diaphragmatic movement and decreasing lung expansion. Clients with respiratory distress should be positioned upright or semi-Fowler’s to facilitate breathing.

B. Instruct the client to perform diaphragmatic breathing: Diaphragmatic breathing helps improve oxygenation and ventilation by promoting deeper, more efficient breaths. It also reduces accessory muscle use and can decrease anxiety associated with shortness of breath.

C. Increase oxygen flow rate to 4 L/min: Oxygen should be titrated to maintain target saturation (usually 92–94% for COPD risk patients). The client’s current oxygen saturation is 92% on 2 L/min, so increasing the flow is unnecessary at this time.

D. Assess the client's breath sounds: Ongoing assessment of breath sounds is essential to monitor for changes such as wheezing, crackles, or diminished air entry, which guide interventions and evaluate response to therapy.

E. Restrict the client's fluid intake: Fluid restriction is not indicated in this client’s current presentation. Adequate hydration helps thin secretions, making coughing and airway clearance more effective.

F. Perform chest percussion and vibration: Chest physiotherapy techniques like percussion and vibration can help loosen and mobilize secretions, improving airway clearance in clients with productive cough and retained secretions.

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Correct Answer is A

Explanation

A. Implement firm but flexible boundaries in their relationship: Establishing boundaries helps both the client and adult child adapt to new caregiving roles while maintaining mutual respect and autonomy. Flexibility allows for adjustments as the client’s needs change, reducing role strain and promoting a healthy family dynamic.

B. Encourage authoritative communication from the adult child: While clear communication is important, an authoritative style may be perceived as controlling and can create tension. Collaborative, respectful communication is more effective in supporting role adjustment and maintaining family harmony.

C. Decrease socialization with extended relatives until roles are identified: Limiting social interactions is unnecessary and may increase isolation or stress. Maintaining connections with extended family can provide emotional support and resources during the transition.

D. Minimize open discussion regarding the changes to avoid embarrassment: Avoiding discussion about changes can lead to misunderstandings, unmet needs, and emotional strain. Open, honest communication helps clarify expectations, reduce conflict, and facilitate adjustment to new roles.

A. Allow extra time for the client to perform tasks. B. Touch the client gently to announce presence. C. Keep objects in the client's room in the same place. D. Approach the client from the side. E. Ensure there is high-wattage lighting in the client's room.

Correct Answer is ["A","C"]

Explanation

A. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to navigate their environment and complete activities safely. Providing extra time reduces stress, supports independence, and promotes a sense of autonomy while performing daily tasks.

B. Touch the client gently to announce presence: The nurse should announce presence verbally first. Touching without warning may startle the client.

C. Keep objects in the client's room in the same place: Maintaining a consistent arrangement of personal items prevents confusion and reduces the risk of falls or accidents. Predictable placement allows the client to perform tasks safely and maintain independence.

D. Approach the client from the side: Approaching from the side is not recommended because it may startle the client. Best practice is to approach from the front while using verbal cues to announce your presence and provide orientation.

E. Ensure there is high-wattage lighting in the client's room: High-intensity lighting may cause glare and discomfort for clients with vision loss, especially those with conditions like macular degeneration. Adequate but non-glare lighting is preferable to support safe mobility.

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A nurse is caring for a client in the emergency department.

Which of the following interventions should the nurse include in the plan of care? Select all that apply.