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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You can take a stool softener to prevent constipation." is correct. After a retinal detachment repair, clients should avoid straining during bowel movements, as increased intracranial pressure could affect the healing eye. Taking a stool softener is a helpful preventive measure to avoid constipation.
B. "You can remove your eye patch during the day." is incorrect. The eye patch should typically be worn continuously to protect the eye and support healing. The surgeon's specific instructions should be followed regarding when the patch can be removed.
C. "You should bend from the waist to pick up objects." is incorrect. After retinal surgery, clients should avoid bending from the waist as this can increase intraocular pressure, potentially compromising the surgical repair. Instead, clients should use proper body mechanics and bend at the knees.
D. "You can apply a warm, moist compress to your forehead to reduce pain." is incorrect. Applying a warm compress to the forehead is not typically recommended following a retinal repair. Clients should follow the specific post-operative instructions from the surgeon, which may include cold compresses or other methods of managing discomfort.
Correct Answer is D
Explanation
A. Positive clonus is a sign of hyperreflexia and can indicate worsening preeclampsia or severe central nervous system irritability. It is not a therapeutic effect of magnesium sulfate.
B. Urinary output 20 mL/hr is below the minimum expected urine output (which is generally 30 mL/hr). This finding suggests oliguria and may be a sign of worsening renal function, which is not a therapeutic effect of magnesium sulfate.
C. Respiratory rate 10/min is too low. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min may indicate toxicity. This is not a therapeutic effect.
D. Deep tendon reflexes 2+ is the correct answer. Magnesium sulfate is used to prevent seizures in preeclampsia by acting as a CNS depressant. A normal response of 2+ for deep tendon reflexes indicates that magnesium sulfate is having a therapeutic effect and the client is not experiencing magnesium toxicity (which would typically cause a decreased reflex response..
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