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 A
Explanation
This demonstrates advocacy for client rights because it respects the client’s autonomy, dignity, and preferences. It also helps the client to make informed decisions about their own health.
Choice B is wrong because telling the client that refusal of the medication is considered noncompliance is coercive and violates the client’s right to refuse treatment.
It also does not address the client’s reasons for refusing the medication or provide any information or education.
Choice C is wrong because informing the client that the medication is the same as taken at home is not enough to ensure that the client understands the purpose, benefits, and risks of the medication.
It also does not verify that the client is taking the medication correctly at home or that there are no changes in the dosage or frequency.
Choice D is wrong because insisting the client takes the prescribed medications is also coercive and violates the client’s right to refuse treatment.
It also does not respect the client’s autonomy, dignity, and preferences.
It may also cause harm to the client if they have an allergy, intolerance, or contraindication to the medication.
Advocacy for nursing stems from a philosophy of nursing in which nursing practice is the support of an individual to promote his or her own well-being, as understood by that individual. It is an ethic of practice that requires nurses to protect and uphold their patients’ rights, values, and interests.
Correct Answer is A
Explanation
Watching television until falling asleep at night is a poor sleep habit because it can interfere with the body’s natural sleep-wake cycle and make it harder to fall asleep and stay asleep. Television can also expose the eyes to bright light and stimulating or stressful content, which can affect the production of melatonin, a hormone that regulates sleep.
Choice B is wrong because having a small snack and taking a bath before going to bed each day are good sleep habits that can promote relaxation and sleep quality.
Choice C is wrong because not taking naps throughout the day is a good sleep habit that can help maintain a consistent sleep schedule and avoid disrupting the night-time sleep.
Choice D is wrong because going to bed and getting up at the same times each day is a good sleep habit that can reinforce the body’s circadian rhythm and make it easier to fall asleep and wake up.
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