After an acute exacerbation of chronic obstructive pulmonary disease (COPD), the nurse prepares an older adult for discharge to home. Which is the most important client teaching for the nurse to include for the prevention of hospitalizations for exacerbations of COPD?
Avoid sick people and wash hands
Use low-flow oxygen for dyspnea
Ease breathing by sitting upright
Eat nutrient- and calorie-dense foods
The Correct Answer is A
Choice A reason: Avoiding sick people and washing hands is the most important client teaching for the nurse to include for the prevention of hospitalizations for exacerbations of COPD, as it can reduce the exposure to respiratory infections, which are the main cause of COPD exacerbations. The nurse would advise the older adult to stay away from people who have colds, flu, or other contagious illnesses, and to wash their hands frequently with soap and water or use alcohol-based hand sanitizer.
Choice B reason: Using low-flow oxygen for dyspnea is a possible client teaching for the nurse to include for the prevention of hospitalizations for exacerbations of COPD, but it is not the most important one, as it depends on the severity of the condition and the oxygen saturation level of the patient. The nurse would advise the older adult to use oxygen therapy as prescribed by their doctor, and to monitor their oxygen level with a pulse oximeter.
Choice C reason: Easing breathing by sitting upright is a helpful client teaching for the nurse to include for the prevention of hospitalizations for exacerbations of COPD, but it is not the most important one, as it is a supportive measure that does not address the underlying cause of the exacerbation. The nurse would advise the older adult to sit upright or lean forward when they have difficulty breathing, and to use pursed-lip breathing or abdominal breathing techniques.
Choice D reason: Eating nutrient- and calorie-dense foods is a beneficial client teaching for the nurse to include for the prevention of hospitalizations for exacerbations of COPD, but it is not the most important one, as it is a long-term strategy that does not prevent the immediate risk of exacerbation. The nurse would advise the older adult to eat a balanced diet that provides enough protein, carbohydrates, fats, vitamins, and minerals, and to avoid foods that can cause gas, bloating, or reflux.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Constipation is the nurse's priority for preventive care, as it is a common and serious side effect of morphine and other opioids, which can slow down the bowel movements and cause hard, dry stools. The nurse would advise the older adult to increase their fiber and fluid intake, use stool softeners or laxatives as prescribed, and report any signs of bowel obstruction, such as abdominal pain, bloating, nausea, or vomiting.
Choice B reason: Poor liquid intake is not the nurse's priority for preventive care, as it is not directly related to the use of morphine, although it can contribute to constipation and dehydration. The nurse would advise the older adult to drink enough fluids, unless they have a fluid restriction, and to monitor their urine output, color, and specific gravity.
Choice C reason: Diarrhea is not the nurse's priority for preventive care, as it is not a common side effect of morphine, although it can occur in some cases due to an allergic reaction, intolerance, or overdose. The nurse would advise the older adult to report any episodes of diarrhea, as it can cause dehydration, electrolyte imbalance, or malabsorption.
Choice D reason: Poor solid food intake is not the nurse's priority for preventive care, as it is not directly related to the use of morphine, although it can affect the nutritional status and wound healing of the older adult. The nurse would advise the older adult to eat a balanced diet that meets their caloric and protein needs, and to avoid foods that can cause gas, indigestion, or constipation.
Correct Answer is D
Explanation
Choice A reason: Organize the reperfusion recombinant tissue plasminogen activator (tPA) infusion is not the appropriate step, as it is a treatment for acute ischemic stroke, which has not been confirmed in this client. tPA is a clot-busting drug that can restore blood flow to the brain, but it has strict criteria and time window for its use. The nurse should not assume that the client has a stroke without further assessment and diagnosis.
Choice B reason: Determine symptom onset or when the fall occurred is not the appropriate step, as it is not the priority for this client. The nurse should first assess the client's vital signs, neurologic status, and potential injuries from the fall. The symptom onset or fall time may be relevant for the diagnosis and treatment of the underlying cause, but it is not the most urgent information to obtain.
Choice C reason: Arrange for a transfer immediately to the radiology department is not the appropriate step, as it is not the most immediate intervention for this client. The nurse should first stabilize the client's condition, perform a thorough assessment, and obtain orders from the medical provider. The radiology department may be needed for diagnostic tests, such as computed tomography (CT) scan or magnetic resonance imaging (MRI), but it is not the first destination for this client.
Choice D reason: Perform a comprehensive neurologic assessment is the appropriate step, as it can help identify the possible cause of the client's balance problem and rule out a stroke or other serious condition. A neurologic assessment includes checking the client's level of consciousness, orientation, speech, cranial nerve function, motor strength, sensory perception, coordination, and reflexes. The nurse should also monitor the client's vital signs, oxygen saturation, and blood glucose levels.
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