A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include?

"Self-administer oxygen through your nasal cannula at 6 milliliters per minute during meals."

"Drink at least 240 milliliters of water during each meal."

"Perform pulmonary hygiene 1 hour before meals."

"Lie down for 30 minutes after eating."

Answer and Explanation

The Correct Answer is C

A. "Self-administer oxygen through your nasal cannula at 6 milliliters per minute during meals." is incorrect. Oxygen should not typically be increased during meals unless specifically prescribed by the provider. If the client has difficulty eating due to breathlessness, a more individualized plan is needed.

B. "Drink at least 240 milliliters of water during each meal." is incorrect. Clients with COPD may have difficulty breathing when consuming large amounts of fluids during meals. Overhydration could also worsen fluid retention in some cases. The amount of fluid should be tailored to the client’s needs and prescribed by the healthcare provider.

C. "Perform pulmonary hygiene 1 hour before meals." is correct. Pulmonary hygiene (such as postural drainage, coughing techniques, and deep breathing exercises) should be performed before meals to clear the airways and improve the ability to breathe while eating, preventing aspiration and difficulty breathing.

D. "Lie down for 30 minutes after eating." is incorrect. Lying down after eating can increase the risk of aspiration, especially in clients with COPD who may already have a compromised respiratory system. The client should be advised to remain upright after meals to prevent reflux and aspiration.

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Correct Answer is D

Explanation

A. Taking the newborn back to the nursery is incorrect. While rest is important for the mother, removing the baby does not help build her confidence or teach her how to respond to her infant’s needs. Supporting her in learning newborn care is more beneficial.

B. Turning the baby on his side to help him sleep is incorrect. The safest sleep position for a newborn is on the back, according to safe sleep guidelines. Additionally, this response does not address the mother's feelings of inadequacy.

C. Explaining that babies cry to develop their lungs is incorrect. While crying is normal for newborns, this response dismisses the client’s concern rather than providing reassurance and support.

D. Showing the mother how to swaddle and cuddle the baby, then letting her try is correct. This approach provides practical guidance and empowers the mother, helping her build confidence in her ability to care for her newborn.

A. "Sit back down for a few minutes when this occurs." B. "Take a daily potassium supplement." C. "Restrict your daily fluid intake." D. "Discontinue this medication if this occurs again."

Correct Answer is A

Explanation

A. "Sit back down for a few minutes when this occurs.": This is correct. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effect. The client should be advised to sit down to prevent falls and allow the body to adjust.

B. "Take a daily potassium supplement.": This is incorrect. ACE inhibitors can increase potassium levels, and taking a potassium supplement without a healthcare provider’s recommendation may lead to hyperkalemia, a dangerous condition.

C. "Restrict your daily fluid intake.": This is incorrect. Dehydration can exacerbate hypotension, so it is not recommended to restrict fluid intake without further instructions from the provider.

D. "Discontinue this medication if this occurs again.": This is incorrect. The client should not discontinue medication without first consulting their healthcare provider. The healthcare provider may adjust the dosage or provide alternative recommendations to manage the side effects.

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A nurse is reinforcing discharge teaching with a client who has COPD and reports problems with maintaining adequate nutrition. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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