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","C","D","E"]

Explanation

A. Measure pulse and blood pressure:
This action is crucial to assess the client's cardiovascular status. Weakness and jitteriness can be related to changes in blood pressure or cardiac function. Measuring pulse and blood pressure helps determine the client's hemodynamic stability.

B. Document anxiety on the surgical checklist:
While anxiety is a valid consideration, addressing the physiological aspects of the client's symptoms takes precedence.

C. Assess skin temperature and moisture:
Assessing skin temperature and moisture provides information about the client's perfusion and hydration status. Changes in skin characteristics can be indicative of underlying issues, and in a diabetic patient, it's important to monitor for potential complications affecting skin integrity.

D. Check fingerstick glucose level:
Given the client's recent diagnosis of type 2 diabetes mellitus and the reported symptoms of weakness and jitteriness, checking the fingerstick glucose level is crucial. Fluctuations in blood glucose levels, whether hyperglycemia or hypoglycemia, can contribute to these symptoms. This test provides immediate information about the client's glycemic status.

E. Administer a PRN dose of regular insulin:
If the fingerstick glucose level indicates hyperglycemia and the healthcare provider has prescribed a PRN (as needed) dose of regular insulin for high blood sugar, administering insulin may be necessary to address hyperglycemia promptly. This is in line with diabetes management protocols, and the nurse should follow specific orders and guidelines for insulin administration.

A. Return appointments will be needed for IV medication. B. Wearing gloves when handling cold items guards against painful spasms. C. Enrolling in a pain clinic can provide pain relief alternatives D. Painful areas should be rubbed gently until the pain subsides.

Correct Answer is B

Explanation

A. Return appointments will be needed for IV medication:
This statement does not address the specific concern related to pain management in Raynaud's disease, and routine IV medication may not be the primary approach for pain relief in this condition.

B. Wearing gloves when handling cold items guards against painful spasms:
This is the correct answer. Raynaud's disease is characterized by vasospasm of small arteries, often triggered by exposure to cold or stress. Wearing gloves helps to minimize exposure to cold and can prevent painful spasms associated with Raynaud's.

C. Enrolling in a pain clinic can provide pain relief alternatives:
While pain clinics can offer various pain management strategies, the specific recommendation for Raynaud's disease involves minimizing exposure to cold and stress rather than enrolling in a pain clinic.

D. Painful areas should be rubbed gently until the pain subsides:
Rubbing painful areas may not be recommended, as it can potentially aggravate vasospasm in individuals with Raynaud's disease. The emphasis is on preventing triggers like cold exposure.

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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

Naxlex Comprehensive Predictor Exams

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

Explanation

A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instruction should the nurse provide?

Correct Answer is B

Explanation

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