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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Prepare the client to return to the operating room:
This is the correct and immediate priority. Evisceration, where internal organs protrude through the surgical incision, is a surgical emergency. Returning the client to the operating room is necessary to assess the extent of the complication, address the wound dehiscence, and protect the exposed organs. This intervention aims to prevent further complications and provide necessary surgical interventions.
B. Obtain a sample of the drainage to send to the lab:
While obtaining samples for laboratory analysis can be important for infection control, in the context of a client with evisceration, the primary concern is the surgical emergency. The priority is to address the wound complication by returning to the operating room rather than focusing on laboratory analysis at this immediate moment.
C. Bring additional sterile dressing supplies to the room:
While bringing additional supplies may be necessary, the priority in this situation is to prepare for the client's return to the operating room. Once the client is in a controlled surgical environment, additional dressing changes and wound care can be performed as needed.
D. Auscultate the abdomen for bowel sound activity:
While monitoring bowel sounds is a routine nursing assessment, in the context of evisceration, the immediate concern is the exposure of internal organs and the risk of infection. Preparing for the operating room takes precedence over routine assessments.

Correct Answer is A
Explanation
A. Drink at least 8 cups (1920 mL) of water per day:
This is the correct answer. Adequate hydration is important in the management of gout because it helps to flush out uric acid and prevent the formation of urate crystals. Increasing fluid intake, especially water, is a key component of gout management.
B. Eat high protein foods to achieve ideal body weight:
While maintaining a healthy weight is important in managing gout, the emphasis should be on a balanced diet that includes adequate hydration and avoidance of foods high in purines, which can contribute to increased uric acid levels.
C. Encourage active range of motion to limit stiffness:
Active range of motion exercises can be beneficial for joint health, but the primary emphasis in gout management is on dietary and pharmacological interventions.
D. Use an electric heating pad when pain is at its worse:
Applying heat may provide some relief, but it is not the primary intervention for gout. Cold compresses or ice may be more appropriate for acute gout attacks.
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