The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

Patient will exhibit O2 saturation > 92% by discharge.

Teach pursed-lip breathing prior to discharge.

Patient will state 2 ways to decrease chance of reinfection by the end of shift.

Patient will demonstrate pursed-lip breathing.

Answer and Explanation

The Correct Answer is C

This is an appropriately constructed goal statement for the client with COPD because it is specific, measurable, attainable, realistic and time-bound (SMART). It also addresses the client’s education needs and promotes self-care.

Choice A is wrong because it is not realistic or attainable for a client with COPD to have O2 saturation > 92% by discharge.

The normal range for O2 saturation is 95-100%, but clients with COPD may have lower levels due to chronic hypoxia.

Choice B is wrong because it is not a goal statement, but an intervention.

A goal statement should describe the expected outcome of the intervention, not the intervention itself.

Choice D is wrong because it is not measurable or time-bound.

A goal statement should have a clear indicator of how and when the outcome will be achieved.

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Correct Answer is A

Explanation

This is because people with COPD are more likely to catch respiratory infections such as colds, flu and pneumonia, which can worsen their symptoms and cause further lung damage. An influenza vaccine can help prevent flu and reduce the risk of complications.

Choice B. A broad-spectrum antibiotic is wrong because antibiotics are only effective against bacterial infections, not viral ones. Antibiotics are usually prescribed for COPD exacerbations caused by bacterial infections, but not for prevention.

Choice C. A bronchodilator is wrong because bronchodilators are medications that relax the muscles around the airways and make breathing easier. They are used to treat the symptoms of COPD, but they do not prevent respiratory infections.

Choice D. A corticosteroid is wrong because corticosteroids are anti inflammatory drugs that reduce swelling and mucus production in the airways. They are also used to treat the symptoms of COPD, but they do not prevent respiratory infections. In fact, long-term use of corticosteroids may increase the risk of infections by suppressing the immune system.

A. Fluid volume excess. B. Risk for infection. C. Ineffective thermoregulation. D. Pain.

Correct Answer is A

Explanation

Fluid volume excess is wrong because appendicitis does not cause fluid retention or overload. It may cause fluid loss due to vomiting, fever, or rupture of the appendix. Therefore, a more appropriate nursing diagnosis would be the risk for deficient fluid volume.

Choice B. Risk for infection is correct because appendicitis is an inflammatory condition that can lead to bacterial infection, especially if the appendix ruptures and causes peritonitis or abscess formation.

Choice C. Ineffective thermoregulation is correct because appendicitis can cause fever due to inflammation and infection.

Choice D. Pain is correct because appendicitis causes acute abdominal pain that usually starts in the periumbilical area and then localizes to the right lower quadrant. The pain may be accompanied by nausea, vomiting, and rebound tenderness.

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The nurse includes which of the following as an appropriately constructed goal statement for the client with COPD?

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Naxlex Comprehensive Predictor Exams

The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD). Which medication does the nurse anticipate to decrease this client’s risk for developing a respiratory infection?

Correct Answer is A

Explanation

Which of the following nursing diagnoses would the nurse be LEAST likely to choose for a patient with appendicitis?

Correct Answer is A

Explanation

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