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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The SBAR is used to organize and standardize communication between members of the health care team about a patient’s condition. It is an acronym for Situation, Background, Assessment, and Recommendation.

Choice B is wrong because the SBAR is not used to help Physical Therapy determine the client’s abilities.

Physical Therapy may use other tools or methods to assess the client’s functional status.

Choice C is wrong because the SBAR is not used to help physicians with diagnoses.

The SBAR is a communication tool, not a diagnostic tool.

Physicians may use other sources of information or tests to make diagnoses.

Choice D is wrong because the SBAR is not used to educate clients about their disease processes.

The SBAR is a tool for interprofessional communication, not for patient education.

Clients may receive education from other sources or materials.

A. The nurse refuses care of the client. B. The nurse delegates all care of the client to an assistant. C. The nurse provides minimal care to keep the client alive. D. The nurse cares for the patient in the same manner as for other clients.

Correct Answer is D

Explanation

This aligns with the professional code of ethics for nurses, which states that nurses should respect the dignity, worth and rights of all human beings, regardless of the nature of their health problems or their social or legal status. The nurse should not let personal feelings or biases interfere with the quality of care or the ethical obligations of the profession.

Choice A is wrong because the nurse refuses to care of the client. This violates the principle of beneficence, which means doing good and preventing harm to others.

The nurse has a duty to provide care to all patients who need it, regardless of their personal opinions or feelings.

Choice B is wrong because the nurse delegates all care of the client to an assistant. This violates the principle of accountability, which means being answerable for one’s actions and decisions. The nurse cannot delegate tasks that require nursing judgment or assessment to an unlicensed person.

The nurse is responsible for ensuring that the patient receives safe and competent care.

Choice C is wrong because the nurse provides minimal care to keep the client alive. This violates the principle of non-maleficence, which means avoiding harm or injury to others.

The nurse should not provide substandard care or neglect the patient’s needs or preferences.

The nurse should strive to promote the health and well-being of the patient.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse utilizes the SBAR format to give report to the next nurse. Which one of the following statements is correct about the SBAR?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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