A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the
following interventions in the plan?

Provide the client with a low protein diet.

Instruct the client to use pursed-lip breathing.

Restrict the client's ﬂuid intake to less than 2 L/day.

Have the client use the early-morning hours for exercise and activity.

Answer and Explanation

The Correct Answer is B

Pursed-lip breathing is a technique that helps clients with COPD to exhale more eﬀectively and prevent air trapping in the lungs. It also reduces dyspnea and improves oxygenation.

a) A low protein diet is not recommended for clients with COPD, as they need adequate protein intake to maintain muscle mass and prevent malnutrition.

c) Fluid restriction is not necessary for clients with COPD, unless they have signs of ﬂuid overload or heart failure. Adequate hydration helps to thin secretions and facilitate expectoration.

d) Early-morning hours are not the best time for exercise and activity for clients with COPD, as they may experience more shortness of breath and fatigue due to diurnal variations in lung function. A better time would be mid-morning or afternoon, after taking bronchodilators and clearing secretions.

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Correct Answer is D

Explanation

Answer: D. Cheyne-Stokes respirations

Rationale:

A) Stridor: Stridor is a high-pitched, wheezing sound resulting from disrupted airflow in the upper airway. It is not characterized by alternating periods of hyperventilation and apnea, making this choice incorrect.

B) Kussmaul respirations: Kussmaul respirations are deep, labored breaths typically associated with metabolic acidosis, such as diabetic ketoacidosis. These respirations do not exhibit alternating periods of hyperventilation and apnea, so this option is not applicable.

C) Apneustic respirations: Apneustic respirations are characterized by prolonged inhalation followed by a prolonged pause before exhalation. This pattern does not align with the alternating hyperventilation and apnea described, making it an incorrect choice.

D) Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by a cyclical pattern of increasing depth and rate of breathing followed by a gradual decrease in depth and a period of apnea. This description matches the client's breathing pattern of alternating hyperventilation and apnea, making this the correct answer.

A. Tilt the client's head backward B. Move the client into high-Fowler's position C. Apply pressure to the nares D. Instruct the client to blow his nose E. Place ice to the bridge of the client's nose

Correct Answer is ["B","C","E"]

Explanation

These actions help to control bleeding, reduce blood pressure, and promote clotting.

a. Tilt the client's head backward. This is not recommended, as it can cause blood to drain into the throat and increase the risk of aspiration, nausea, or vomiting.

d. Instruct the client to blow his nose. This is not advisable, as it can dislodge any clots that have formed and worsen bleeding.

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A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

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A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the
following interventions in the plan?