A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea.
To promote intake, which of the following actions should the nurse include in the plan of care?

Administer a bronchodilator after meals.

Ambulate the client before each meal.

Limit fluid intake with meals.

Offer the client three large meals each day.

Answer and Explanation

The Correct Answer is C

The correct answer is choice c. Limit fluid intake with meals.

Choice A rationale:

Administering a bronchodilator after meals is not ideal because bronchodilators are typically given before meals to help open the airways and make breathing easier during eating.

Choice B rationale:

Ambulating the client before each meal might cause fatigue, making it harder for the client to eat and potentially decreasing their overall intake.

Choice C rationale:

Limiting fluid intake with meals can help prevent the client from feeling too full, which can make it easier for them to consume more solid food. This is particularly important for clients with COPD who may already have a reduced appetite and difficulty eating large amounts at once.

Choice D rationale:

Offering three large meals each day is not recommended for clients with COPD. Smaller, more frequent meals are generally better tolerated and can help prevent the feeling of fullness that can make breathing more difficult.

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Correct Answer is B

Explanation

Choice A rationale:

Recent myocardial infarction is not a contraindication for warfarin administration. Warfarin is often prescribed for patients with a history of myocardial infarction to prevent clot formation and reduce the risk of stroke.

Choice B rationale:

Recent eye surgery is a contraindication for the administration of warfarin. Warfarin can increase the risk of bleeding, which is particularly concerning after eye surgery due to the delicate nature of ocular tissues. Using anticoagulants in this scenario can lead to severe complications, including vision loss.

Choice C rationale:

Thrombophlebitis, inflammation of a vein with clot formation, is not a contraindication for warfarin administration. In fact, anticoagulants like warfarin are commonly prescribed to prevent the extension of clots and reduce the risk of complications associated with thrombophlebitis.

Choice D rationale:

Breast cancer is not a direct contraindication for warfarin administration. However, the decision to use anticoagulants in patients with a history of breast cancer should be made carefully, considering individual factors such as the stage of cancer, ongoing treatment, and overall risk of thromboembolic events.

A. Lift the penis so that it is perpendicular to the client's body. B. Cleanse the tip of the penis in a side-to-side motion. C. Pick up the catheter 13 cm (5 in) from its tip. D. Inflate the catheter balloon before insertion.

Correct Answer is A

Explanation

The correct answer is choiceA. Lift the penis so that it is perpendicular to the client’s body.

Choice A rationale:

Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.

Choice B rationale:

While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.

Choice C rationale:

Picking up the catheter 13 cm (5 in) from its tip is not a standard practice.The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.

Choice D rationale:

Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended.The balloon should only be inflated once the catheter is correctly positioned in the bladder.

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A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea. To promote intake, which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

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A nurse is developing a nutritional care plan for a client who has COPD and severe dyspnea.
To promote intake, which of the following actions should the nurse include in the plan of care?