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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Correct Answer is ["B","D"]

Explanation

A. Use standard precautions and wear a mask:
The use of standard precautions is appropriate for general care to prevent the transmission of infectious agents. However, specific to MRSA, additional precautions are needed. Wearing a mask is generally not necessary unless the client has respiratory symptoms that warrant respiratory precautions.

B. Institute contact precautions for staff and visitors:
This is a correct intervention. Contact precautions involve using gowns and gloves when providing care to prevent the transmission of MRSA. It is important for both healthcare staff and visitors to adhere to contact precautions to reduce the risk of spreading the infection.

C. Explain the purpose of a low bacteria diet:
The purpose of a low bacteria diet is generally unrelated to the management of MRSA. Low bacteria diets are often recommended for individuals with compromised immune systems to reduce the risk of foodborne infections. However, it may not be directly applicable to MRSA management.

D. Monitor the client's white blood cell count:
Monitoring the white blood cell count is a relevant intervention. An elevated white blood cell count may indicate an ongoing infection or an inflammatory response. Regular monitoring helps assess the client's immune response and the potential severity of the infection.

A. Skin elasticity. B. Urinary output. C. Oxygen saturation. D. Lung sounds. E. Pain scale.

Correct Answer is ["B","C","D"]

Explanation

A. Skin elasticity:
Assessing skin elasticity is a measure of hydration status. Improved skin turgor may suggest that the client is responding positively to diuretic therapy by eliminating excess fluid. However, this may not be as immediate or specific as other indicators of response.

B. Urinary output:
Monitoring urinary output is crucial when administering diuretics like furosemide. Increased urine output indicates that the diuretic is promoting the elimination of excess fluid from the body, which is a desired effect in managing heart failure and fluid overload.

C. Oxygen saturation:
Assessing oxygen saturation is important in monitoring respiratory status. Improvement in oxygen saturation levels indicates that the client is responding to interventions aimed at relieving respiratory distress, such as the administration of furosemide.

D. Lung sounds:
Monitoring lung sounds is a key aspect of assessing respiratory function. Reduction in wheezes and crackles suggests that the diuretic is helping to alleviate pulmonary congestion and fluid accumulation in the lungs, contributing to improved respiratory function.

E. Pain scale:
Assessing pain is relevant if the client has reported chest pain or discomfort associated with heart failure. Reduction in pain may indicate improved cardiac function and response to treatment. However, it's important to note that pain assessment may not be as specific to the effects of furosemide as other respiratory and fluid status indicators.

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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?

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Correct Answer is ["B","D"]

Explanation

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Explanation

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