Struggling to breathe, an older adult client with end-stage chronic obstructive pulmonary disease (COPD) is admitted through the emergency department. The client is anxious and considering mechanical ventilation when the spouse interrupts the nurse and hands the nurse a copy of the client’s living will. Which action is most important for the nurse to take?

Facilitate a family meeting with the palliative care team.

Alert the nursing staff of the client’s do not resuscitate wishes.

Place a certified copy of the living will in the client’s electronic health record (EHR).

Notify the healthcare provider of the client’s wishes.

Answer and Explanation

The Correct Answer is D

Choice A reason: Facilitating a family meeting with palliative care discusses end-of-life goals in COPD, where airway obstruction causes respiratory failure. However, notifying the provider of the living will ensures immediate alignment with the client’s wishes, especially on ventilation, addressing the urgent need to respect legal directives in a critical scenario.

Choice B reason: Alerting staff about do-not-resuscitate (DNR) wishes assumes the living will specifies DNR, which requires confirmation. The provider must review the document first, as end-stage COPD necessitates clarity on ventilation preferences to guide urgent care, making notification the priority over premature staff alerts.

Choice C reason: Placing the living will in the EHR ensures documentation but does not immediately affect care. In end-stage COPD with respiratory distress, notifying the provider ensures the client’s wishes, like avoiding intubation, are followed promptly, preventing unwanted interventions, making this more urgent than administrative tasks.

Choice D reason: Notifying the provider of the living will is critical, as it legally specifies the client’s preferences, potentially refusing ventilation in end-stage COPD, where dyspnea results from irreversible obstruction. This ensures treatment respects autonomy, guiding immediate care to align with palliative goals, preventing inappropriate interventions during a crisis.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Strict bedrest is not indicated for urolithiasis, as movement may aid stone passage by shifting ureteral dynamics. Severe flank pain from ureteral obstruction causes muscle spasms. Straining urine collects stones for analysis, identifying composition to guide treatment, making bedrest less critical than addressing the stone.

Choice B reason: Limiting fluid intake is contraindicated, as high fluids promote urine flow, aiding stone passage and diluting urinary solutes like calcium. Pain results from obstruction, and straining urine identifies stone type. Fluid restriction increases stone formation risk, making this harmful and counterproductive to urolithiasis management.

Choice C reason: Straining all urine collects stones for analysis, determining composition (e.g., calcium oxalate) to guide dietary and pharmacological prevention. Severe flank pain from ureteral obstruction highlights the need for stone identification. This addresses the pathophysiological cause, enabling tailored interventions to prevent recurrence and manage acute symptoms.

Choice D reason: A high-calcium diet is inappropriate, as most kidney stones are calcium-based. Dietary calcium moderation, based on stone analysis from straining urine, prevents recurrence. Pain management requires stone identification, not increased calcium intake, which could exacerbate stone formation, making this counterproductive for urolithiasis.

A. Obtain an arterial blood gas (ABG) prior to the procedure. B. Explain that the client may be placed in five positions. C. Perform the drainage immediately after meals. D. Instruct the client to breathe shallow and fast.

Correct Answer is B

Explanation

Choice A reason: Obtaining an ABG assesses oxygenation in COPD but is not needed before postural drainage, which mobilizes secretions. ABGs are invasive, used for exacerbations. Explaining positions prepares the client, enhancing cooperation for effective mucus clearance, addressing airway obstruction without unnecessary invasive testing.

Choice B reason: Postural drainage uses gravity in five positions (e.g., Trendelenburg, lateral) to drain lung segments in COPD, where mucus obstructs airways. Explaining this reduces anxiety, ensuring cooperation, optimizing secretion clearance to improve ventilation and gas exchange, addressing the pathophysiological need for airway clearance.

Choice C reason: Drainage after meals risks aspiration, as a full stomach increases reflux in positions like Trendelenburg. COPD’s mucus retention obstructs airways, and timing drainage appropriately enhances efficacy. Explaining positions ensures effective procedure execution, avoiding complications like aspiration, making this approach unsafe.

Choice D reason: Shallow, fast breathing is contraindicated in COPD, where deep, slow breaths reduce air trapping and improve alveolar ventilation. Postural drainage clears mucus, and proper breathing enhances efficacy. Explaining positions prepares the client, optimizing outcomes, making this instruction incorrect for effective breathing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with urolithiasis who reports severe flank and abdominal pain. Which action should the nurse implement?

Correct Answer is C

Explanation

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

Correct Answer is B

Explanation

After a week of bedrest, a client is being assisted to a chair for the first time. The nurse raises the head of the bed and moves the client to a sitting position. Which action should the nurse implement next?

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of “coffee ground” drainage. Which action should the nurse implement?

Which instruction should the nurse provide a client who was recently diagnosed with Raynaud’s disease?

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, “Improvement in avolition prior to discharge.” Which behavior demonstrates achievement of this goal to the nurse?

Prior to initiating digital removal of a fecal impaction, it is most important for the nurse to perform which client assessment?

Following admission for a cardiac catheterization, the nurse is providing discharge teaching to the parents of a 2-year-old toddler with Tetralogy of Fallot. Which instruction should the nurse give the parents if their child becomes pale, cool, and lethargic?

At 0800, the practical nurse (PN) reports to the registered nurse (RN) that a client’s blood pressure is 140/90 mm Hg. When the RN arrives to administer the 0900 antihypertensive medication, the client is oriented but lethargic, pale, and diaphoretic. Which action should the RN implement first?

A client with gastroesophageal reflux disorder (GERD), who has been self-medicating with famotidine for the past week, is admitted to the acute care center because the symptoms have worsened. The nurse should anticipate which treatment?