A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?
Instruct the client to use pursed-lip breathing.
Plan to have the client lay down for 1 hr after meals.
Restrict the client’s fluid intake to less than 1 L/day.
Encourage the client to use the upper chest for respiration.
The Correct Answer is A
Pursed-lip breathing is a technique that helps to slow down the breathing rate and keep the airways open longer. This improves gas exchange and reduces the work of breathing. Pursed-lip breathing also helps to prevent air trapping and hyperinflation of the lungs, which are common complications of COPD.
Choice B is wrong because laying down for 1 hour after meals can increase the pressure on the diaphragm and make breathing more difficult. It can also increase the risk of aspiration and reflux.
Choice C is wrong because restricting the client’s fluid intake to less than 1 L/day can lead to dehydration and thickening of secretions, which can obstruct the airways and impair gas exchange. Fluid intake should be adequate to maintain hydration and thin secretions.
Choice D is wrong because using the upper chest for respiration is a sign of inefficient breathing and respiratory distress.
It can increase the oxygen demand and cause fatigue. The client should be encouraged to use the diaphragm and abdominal muscles for respiration, which are more efficient and reduce the work of breathing.
Normal ranges for oxygen saturation are 95% to 100%, for arterial blood gas pH are 7.35 to 7.45, for PaCO2 are 35 to 45 mmHg, for PaO2 are 80 to 100 mmHg, and for HCO3 are 22 to 26 mEq/L.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
These are signs of anemia, which is a condition in which the blood lacks enough healthy red blood cells to carry adequate oxygen to the body’s tissues.
Anemia can cause fatigue, weakness, pale skin, cold hands and feet, dizziness, reduced immunity and shortness of breath.
Choice A is wrong because bradypnea is abnormally slow breathing, which is not a sign of anemia. Anemia can cause tachypnea, which is abnormally fast breathing.
Choice E is wrong because flushed skin is not a sign of anemia. Anemia can cause pallor, which is pale or yellowish skin.
Flushed skin can be a sign of other conditions, such as fever, infection or allergic reaction.
Normal ranges for hemoglobin levels vary depending on age and gender. For adult males, the normal range is 13.5 to 17.5 grams per deciliter (g/dL) of blood. For adult females, the normal range is 12 to 15.5 g/dL of blood.
Correct Answer is A
Explanation
This is because hypokalemia (low potassium level in the blood) can cause abnormal heart rhythms (arrhythmia) that can be life-threatening and require urgent medical attention. A cardiac monitor can help detect and treat any arrhythmia that may occur.
Choice B is wrong because administering a laxative can worsen hypokalemia by causing more potassium loss through the digestive tract. Laxative use is one of the possible causes of hypokalemia.
Choice C is wrong because placing the client on seizure precautions is not a priority intervention for hypokalemia. Seizures are not a common symptom of hypokalemia, although muscle weakness and cramps may occur.
Choice D is wrong because restricting high potassium foods is not a priority intervention for hypokalemia. In fact, increasing potassium intake through foods or supplements may be helpful in less serious cases of hypokalemia. However, this should be done according to the doctor’s recommendation and with careful monitoring of blood potassium levels.
Normal blood potassium levels for an adult range from 3.6 to 5.2 millimoles per liter (mmol/L). A very low potassium level (less than 2.5 mmol/L) can be life threatening.
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