A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make?

"Have your head turned to the side while you lie on your stomach."

"Lie on your back with your head and shoulders supported by a pillow."

"Have a table beside your bed so you can sit on the side of the bed and rest your arms on the table."

"Lie on your side with your top arm resting on the bed and your weight on your hip."

Answer and Explanation

The Correct Answer is C

A. "Have your head turned to the side while you lie on your stomach.": This is the prone position, which can worsen breathing in COPD clients.
B. "Lie on your back with your head and shoulders supported by a pillow.": This is the supine or semi-Fowler’s position, which may not optimize lung expansion.
C. "Have a table beside your bed so you can sit on the side of the bed and rest your arms on the table.": This is the orthopneic or tripod position, which facilitates diaphragmatic expansion and improves breathing in clients with COPD.
D. "Lie on your side with your top arm resting on the bed and your weight on your hip.": This is a lateral position, which doesn't significantly aid breathing in COPD.

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Correct Answer is A

Explanation

A. Carbon monoxide poisoning: CO poisoning presents with nonspecific symptoms like nausea, headache, dizziness, and cherry-red mucous membranes. Furnaces can emit CO if not ventilated properly.
B. Stress: Stress can cause headaches and fatigue, but not vertigo or cherry-red mucosa.
C. Septic shock: Septic shock typically presents with hypotension, fever or hypothermia, and poor perfusion-not cherry-red mucosa.
D. Heat stroke: Heat stroke causes high body temperature, altered mental status, and dry skin-not related to furnace use or cherry-red mucosa.

A. Inserts one finger between the client's wrist and the restraint B. Ties the restraints to the side rails C. Places the padding of the restraints against the client's bony prominences D. Ties the straps of the restraints in a double knot

Correct Answer is C

Explanation

A. Inserts one finger between the client's wrist and the restraint: Best practice is to allow two fingers of space to ensure adequate circulation and comfort.
B. Ties the restraints to the side rails: Restraints must never be tied to movable parts (like side rails); they should be secured to the bed frame.
C. Places the padding of the restraints against the client's bony prominences: Padding helps prevent skin breakdown and pressure injuries over bony areas.
D. Ties the straps of the restraints in a double knot: Double knots are hard to remove in emergencies; a quick-release knot is recommended.

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A nurse is instructing a client who has COPD about using the orthopneic position to relieve shortness of breath. Which of the following statements should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse in a clinic is collecting data from a client who reports nausea, headache, weakness, and vertigo after turning on his furnace. The client's oral mucous membranes are cherry red. Then nurse should associate the client's manifestations with which of the following conditions?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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