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 B
Explanation
A. Irrigating the catheter manually:
Manually irrigating the catheter without an order may disrupt the clotting process and increase the risk of bleeding. It is not a routine nursing intervention post-TURP without specific orders.
B. Monitoring catheter drainage.
It is not within the nurse's scope of practice to manually irrigate the catheter without a healthcare provider's order, especially in the context of post-TURP care. The dark, pink-tinged outflow with blood clots indicates some expected bleeding following the procedure. The nurse should closely monitor the catheter drainage for the amount, color, and presence of clots.
C. Discontinuing infusing solution:
Discontinuing the normal saline irrigation may lead to clot formation and obstruction, potentially worsening the situation. The continuous bladder irrigation is often used to prevent clot formation and maintain catheter patency post-TURP.
D. Decreasing the flow rate:
The flow rate is typically set by the healthcare provider to maintain catheter patency and prevent clot formation. Decreasing the flow rate without specific orders may not be appropriate in this situation.
Correct Answer is D
Explanation
A. Remind the client to practice pelvic floor (Kegel) exercises regularly.
Pelvic floor exercises, such as Kegel exercises, are typically recommended for conditions involving weakened pelvic floor muscles. However, in the context of urinary retention related to sensorimotor deficits in multiple sclerosis, the issue is more neurological in nature. Therefore, pelvic floor exercises may not address the underlying problem effectively.
B. Provide a bedside commode for immediate use in the client's room.
While a bedside commode may be beneficial for individuals with mobility issues, it doesn't directly address the problem of urinary retention. It focuses on providing a convenient means for the client to void when needed, but it doesn't address the inability to empty the bladder spontaneously.
C. Explain the need to limit intake of oral fluids to reduce client discomfort.
Limiting oral fluids is not an appropriate intervention for urinary retention. In fact, it could lead to dehydration, which is not a recommended approach. The focus should be on addressing the difficulty in voiding through appropriate techniques.
D. Teach the client techniques for performing intermittent catheterization.
This is the correct choice. Intermittent catheterization is a direct and effective method to manage urinary retention in clients with sensorimotor deficits. Teaching the client how to perform intermittent catheterization empowers them to maintain regular bladder emptying and prevent complications associated with urinary retention.
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