A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The nurse positions the client in the orthopneic position. What is the primary reason for the use of this position for this client?
Prevents pressure ulcers.
Supports hip extension.
Facilitates breathing.
Promotes urinary elimination.
The Correct Answer is C
Choice A Reason:
“Prevents pressure ulcers” is incorrect. While positioning can help prevent pressure ulcers, the orthopneic position is specifically used to aid in breathing rather than to prevent pressure ulcers. Pressure ulcers are typically managed by regularly repositioning the client and using pressure-relieving devices.
Choice B Reason:
“Supports hip extension” is incorrect. The orthopneic position does not primarily support hip extension. This position involves sitting up and leaning forward, which does not significantly affect the hips.
Choice C Reason:
“Facilitates breathing” is correct. The orthopneic position, also known as the tripod position, helps to improve breathing in clients with COPD. By leaning forward and resting the arms on a table or knees, the diaphragm can move more freely, and accessory muscles of respiration are better utilized, reducing the work of breathing.
Choice D Reason:
“Promotes urinary elimination” is incorrect. The orthopneic position is not intended to promote urinary elimination. Urinary elimination is typically managed through other interventions such as ensuring adequate hydration and, if necessary, using a catheter.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Retrieving the blood from the laboratory and running each unit at an 8-hour rate is not appropriate. According to transfusion guidelines, blood products should be infused within 4 hours to prevent bacterial growth and reduce the risk of transfusion-related complications1. Infusing blood over 8 hours increases the risk of these complications.
Choice B Reason:
Notifying the laboratory to split the unit into 2 and then infusing each half for 4 hours is also not ideal. While this approach might seem to address the time constraint, it is not a standard practice and could lead to issues with blood product integrity and patient safety2. Blood products are typically not split unless there are specific protocols in place, and this is not a common intervention for managing infusion rates.
Choice C Reason:
Calling the HCP to question the order is the correct intervention. Blood transfusions must be completed within 4 hours to ensure patient safety and maintain the integrity of the blood product3. The nurse should advocate for the patient by questioning any orders that do not align with established guidelines and best practices.
Choice D Reason:
Infusing each unit for 8 hours is incorrect. The maximum duration for infusing a unit of blood is 4 hours4. Extending the infusion time beyond this limit increases the risk of complications such as bacterial contamination and reduced efficacy of the blood product.
Correct Answer is A
Explanation
Choice A Reason:
Mobilizes secretions is correct. Expectorants work by thinning and loosening the mucus in the airways, making it easier to cough up and expel. This helps clear the respiratory tract of mucus and other secretions, making the cough more productive.
Choice B Reason:
Suppresses the urge to cough is incorrect. This describes the action of antitussives, not expectorants. Antitussives work by suppressing the cough reflex, which is different from the mechanism of expectorants.
Choice C Reason:
Reduces inflammation is incorrect. While reducing inflammation can help with respiratory symptoms, it is not the primary mechanism of action for expectorants. Anti-inflammatory medications are used to reduce inflammation.
Choice D Reason:
Dries mucous membranes is incorrect. Drying mucous membranes is typically the action of antihistamines, not expectorants. Expectorants aim to increase the moisture in mucus to make it less sticky and easier to expel.
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