The nurse provides care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). The patient's pulse oximetry is 93% on room air with a current respiratory rate of 35 breaths per minute. The most recent chest x-ray indicates a flattened diaphragm with infiltrates. The patient is currently febrile with an increased number of white blood cells (WBCs) noted on the latest complete blood count (CBC). Which order does the nurse question for this patient based on the current data?
Chest physiotherapy (CPT) every 4 hours while awake
Oxygen therapy via nasal cannula at 3 to 4 L/min
Add humidification to the oxygen source
Raise the head of the patient's bed
The Correct Answer is A
A. Chest physiotherapy (CPT) every 4 hours while awake. CPT is used to mobilize secretions but may be too aggressive for a patient with infiltrates and respiratory distress, as it can increase fatigue and worsen respiratory status.
B. Oxygen therapy via nasal cannula at 3 to 4 L/min. Low-flow oxygen therapy is often used in COPD to prevent hypoxemia while avoiding CO₂ retention.
C. Add humidification to the oxygen source. Humidified oxygen helps prevent airway dryness and improves secretion clearance, which is beneficial for COPD patients.
D. Raise the head of the patient's bed. Elevating the head of the bed promotes lung expansion and improves oxygenation, making this an appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. HCO3 above 26 mEq/L: This would indicate metabolic alkalosis, not metabolic acidosis.
B. pH below 7.35: Metabolic acidosis is characterized by a low pH (<7.35) due to excess acid accumulation or bicarbonate loss.
C. PaCO2 above 45 mm Hg: PaCO2 above 45 mm Hg is seen in respiratory acidosis, not metabolic acidosis.
D. PaO2 below 70 mm Hg: A low PaO2 indicates hypoxemia, which can occur alongside acidosis but is not a defining feature of metabolic acidosis.
Correct Answer is D
Explanation
A. "The goal for your pain is 0 on a 0 to 10 scale.": A pain score of 0 may not always be realistic postoperatively. The goal is pain control, not complete elimination.
B. "It is better not to have visitors if you are in pain.": Social support can be beneficial in pain management, and visitors should not necessarily be restricted unless the patient finds them distressing.
C. "You will be given the lowest strength pain medication first.": Pain management is individualized, and stronger analgesics may be needed initially, especially after surgery.
D. "It is important that you request pain medication before the pain gets too severe.": Preemptive pain management helps prevent pain from becoming severe and difficult to control. Patients should be encouraged to ask for medication before pain intensifies.
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