A patient with chronic obstructive pulmonary disease (COPD) on daily prednisone therapy has been eating very little and has lost weight. Which interventions are appropriate for the nurse to include in the care plan? Select all that apply.

Offer high-calorie protein snacks between meals and at bedtime.

Encourage increased intake of whole grains and vegetables.

Encourage rest before meals.

Provide a large glass of juice with each meal.

Answer and Explanation

Correct Answer : A,C

Choice A reason: Offering high-calorie protein snacks between meals and at bedtime is appropriate for a patient with COPD who is losing weight and eating very little. These snacks can help meet their nutritional needs and provide the extra calories and protein necessary to prevent muscle wasting and support overall health.

Choice B reason: While increasing the intake of whole grains and vegetables is generally healthy, it may not be the priority for a patient who has lost significant weight and needs to focus on higher-calorie, nutrient-dense foods. The primary goal is to address the calorie and protein deficit first.

Choice C reason: Encouraging rest before meals is beneficial as it helps conserve energy for eating. Patients with COPD often experience fatigue, which can reduce their appetite and ability to eat. Resting before meals can help them feel more energetic and better able to consume their meals.

Choice D reason: Providing a large glass of juice with each meal is not ideal for increasing calorie and protein intake. While juice can provide some calories and nutrients, it is not a good source of protein. Additionally, large volumes of liquid can create a feeling of fullness, reducing the patient's appetite for nutrient-dense foods.

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Correct Answer is B

Explanation

Choice A reason: Urine output of 30 mL/hr is concerning as it is on the lower end of normal and can indicate dehydration or impaired renal function. However, in this context, it is less immediately alarming compared to severely low blood pressure.

Choice B reason: Blood pressure of 90/40 is critically low and indicates hypotension, which can be a sign of severe dehydration or shock, especially in a patient with ongoing nausea and vomiting. This requires immediate attention and intervention to stabilize the patient and prevent further complications.

Choice C reason: An infiltrated IV site is a problem that needs to be addressed to ensure proper administration of fluids and medications. However, it is not as immediately life-threatening as hypotension.

Choice D reason: Oral fluid intake of 100 mL for 8 hours is inadequate, suggesting that the patient may be dehydrated. While concerning, it is not as acutely critical as low blood pressure, which directly affects perfusion and organ function.

A. Respiratory status B. Liver enzymes C. Blood pressure D. Neurological status E. Potassium level

Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Respiratory status is crucial to monitor because patients with acute neurological deficits, such as those seen in strokes, are at risk of respiratory compromise. This can be due to weakened respiratory muscles or aspiration, which could lead to pneumonia or other respiratory complications.

Choice B reason: Monitoring liver enzymes is not directly related to the acute management of a stroke patient. Liver enzymes would be more relevant in cases where liver function or hepatic issues are suspected, but not for this specific scenario.

Choice C reason: Blood pressure monitoring is vital, as hypertension is a significant risk factor for stroke. Maintaining appropriate blood pressure is essential to prevent further neurological damage and complications. Acute changes in blood pressure can indicate worsening or improvement of the patient's condition.

Choice D reason: Neurological status should be continuously monitored to assess the progression of the patient's stroke symptoms. This includes checking for changes in level of consciousness, motor function, speech, and other neurological signs. Prompt detection of changes can guide immediate interventions.

Choice E reason: Potassium level monitoring is not a primary focus in the acute management of stroke. While electrolyte balance is important, it is not as critical as respiratory status, blood pressure, and neurological status in this context.

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A patient with chronic obstructive pulmonary disease (COPD) on daily prednisone therapy has been eating very little and has lost weight. Which interventions are appropriate for the nurse to include in the care plan? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

Correct Answer is B

Explanation

Correct Answer is ["A","C","D"]

Explanation

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