An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?

Administer a prescribed sedative

Assist client to an upright position.

Encourage client to drink water

Apply a high-flow venturi mask.

Answer and Explanation

The Correct Answer is B

A. Administer a prescribed sedative:
Sedatives may depress the respiratory drive, which can be detrimental in a client with respiratory distress. It is not the appropriate intervention in this case.

B. Assist the client to an upright position.
Positioning the client upright helps improve respiratory mechanics by reducing the pressure on the diaphragm and allowing better lung expansion. This position can enhance the efficiency of breathing and alleviate symptoms of breathlessness.

C. Encourage the client to drink water:
While maintaining hydration is important, it may not directly address the immediate respiratory distress. Addressing the respiratory symptoms with an upright position is more crucial at this moment.

D. Apply a high-flow venturi mask:
While oxygen therapy may be necessary for a client with COPD experiencing respiratory distress, the first step is to assist the client to an upright position to improve respiratory mechanics. Applying a high-flow venturi mask may be a subsequent intervention based on the overall assessment, but positioning is the initial priority.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Family members can help with regular foot exams:
This is the correct answer. Regular foot exams are essential for individuals with diabetes, especially those with peripheral neuropathy. Family members can assist in identifying any changes, cuts, or wounds on the feet that the client might not be able to perceive due to neuropathy.

B. Heating pads are useful if on the lowest setting:
The use of heating pads is generally not recommended for individuals with peripheral neuropathy. They may have reduced sensation, making it difficult to detect if the pad is too hot, leading to the risk of burns.

C. Aching feet may be soaked in lukewarm water for one hour or more:
Prolonged soaking of feet is not advisable, as it can lead to maceration of the skin and increase the risk of infection. A short, lukewarm foot soak is generally acceptable, but the duration should be limited.

D. Shoes should be worn outside the house, but it is fine to be barefoot inside:
Individuals with diabetes and peripheral neuropathy should wear protective footwear both inside and outside the house to prevent injuries and reduce the risk of complications.

A. Hypovolemia and electrocardiographic (ECG) changes. B. Uremic irritation of mucous membranes and skin surfaces. C. Side effects of total parental nutrition (TPN) and Intralipids. D. Elevated creatinine and blood urea nitrogen (BUN)

Correct Answer is A

Explanation

A. Hypovolemia and electrocardiographic (ECG) changes:
During the diuretic phase of AKI, there is an increased urine output, and the risk of dehydration and hypovolemia is elevated. The nurse should closely monitor fluid balance to prevent dehydration, and ECG changes may occur due to electrolyte imbalances (such as hypokalemia) associated with diuresis.

B. Uremic irritation of mucous membranes and skin surfaces:
Uremic symptoms are more prominent in the oliguric phase of AKI when waste products accumulate in the blood. In the diuretic phase, the focus shifts more toward managing fluid and electrolyte balance.

C. Side effects of total parental nutrition (TPN) and Intralipids:
TPN and Intralipids are not directly related to the diuretic phase of AKI. Monitoring for side effects of TPN and Intralipids may be relevant in other clinical contexts but is not the primary concern in the diuretic phase.

D. Elevated creatinine and blood urea nitrogen (BUN):
Monitoring creatinine and BUN levels is important for assessing kidney function, but in the diuretic phase, the focus shifts to managing fluid and electrolyte balance. The risk of hypovolemia and electrolyte imbalances is more immediate during this phase.

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An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?

Nursing Test Bank

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