Question

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Answer 1

Correct Answers:

Instruct the client to use pursed-lip breathing.

Rationale :

🫁Pursed-lip breathing helps clients with COPD improve ventilation and gas exchange by prolonging exhalation, which prevents airway collapse and reduces air trapping.

🧘This breathing technique also promotes relaxation and decreases dyspnea during exertion or anxiety.

📉It helps to lower carbon dioxide levels and increase oxygenation, which is critical in preventing respiratory acidosis in COPD.

🚫A low protein diet is contraindicated as protein is essential for tissue repair and immune function in these patients.

📌Core Message

Pursed-lip breathing improves oxygenation and reduces air trapping in COPD by prolonging exhalation and enhancing gas exchange efficiency.

Answer 2

Correct Answers:

"You may feel scared. Let's talk about what you are afraid of."

Rationale :

🗣️Acknowledging the client’s feelings is a central aspect of therapeutic communication and helps establish trust between the nurse and the client.

✒️This open-ended response invites the client to express concerns and fears, which can help in addressing emotional distress related to surgery or smoking history.

💬Statements that dismiss the client’s concerns or shift focus away from their emotions can hinder emotional processing and reduce the quality of care.

🧍Empathetic engagement is vital, especially before invasive procedures like a lobectomy, to promote psychological readiness and coping.

📌Core Message

Use therapeutic communication to encourage clients to express their fears, helping them cope emotionally before major procedures.

Answer 3

Correct Answers:

Place in a prone position.

Rationale :

🖋️Prone positioning improves oxygenation in clients with ARDS by promoting better alveolar recruitment and improving ventilation-perfusion matching.

📈It reduces the pressure of the heart and abdominal organs on the lungs, enhancing lung compliance and decreasing intrapulmonary shunting.

🛑Low-flow oxygen is usually inadequate for ARDS; these clients typically require mechanical ventilation with higher oxygen concentrations.

🥗Nutritional support is important but not the priority; positioning directly impacts respiratory mechanics, which are compromised in ARDS.

📌Core Message

Prone positioning enhances oxygenation and alveolar function in ARDS, making it a critical non-invasive intervention.

Answer 4

Correct Answers:

Keep the drainage system below the level of the clients chest at all times.

Rationale :

📉Keeping the drainage system below chest level utilizes gravity to facilitate drainage of air or fluid and prevents backflow into the pleural space.

🔒Backflow can lead to tension pneumothorax or reaccumulation of fluid, posing serious risks to the client’s respiratory status.

🚫Clamping the chest tube can result in increased intrathoracic pressure and should be avoided unless absolutely necessary under medical supervision.

🧳During transport, maintaining the integrity and positioning of the system is crucial to prevent complications and ensure effective drainage.

📌Core Message

Proper positioning of the chest drainage system is essential to ensure gravity-assisted drainage and prevent complications like pneumothorax.

Answer 5

Correct Answers:

"Use a bronchodilator I hour before eating."

Rationale :

🫁Using a bronchodilator before meals reduces dyspnea and opens airways, allowing the client to eat more comfortably without respiratory distress.

🍽️Clients with COPD often experience early satiety and fatigue during meals, so optimizing breathing beforehand supports better nutritional intake.

🥤Small, frequent meals are preferred over large ones to reduce abdominal distension, which can impair diaphragmatic movement.

💧Water intake should not be restricted, and protein intake should be maintained or increased to support muscle maintenance and immune function.

📌Core Message

Bronchodilators before meals improve airway patency, allowing COPD clients to eat with less breathlessness, supporting better nutrition.

Answer 6

Correct Answers:

Increased anteroposterior diameter of the chest

Rationale :

📏Barrel chest or increased anteroposterior diameter is a classic physical finding in clients with emphysema, a form of COPD, due to chronic lung hyperinflation.

🌬️Air trapping causes overdistension of the alveoli, leading to changes in the chest wall configuration over time.

📉Oxygen saturation is often lower than normal in these clients due to impaired gas exchange.

🩺Respiratory alkalosis is not typical in advanced emphysema; respiratory acidosis is more common due to CO2 retention.

📌Core Message

Emphysema leads to chronic hyperinflation, causing a barrel-shaped chest and reduced pulmonary elasticity.

Answer 7

Correct Answers:

Oral candidiasis

Rationale :

👄Fluticasone is an inhaled corticosteroid, which can suppress local immunity in the oral mucosa and lead to fungal overgrowth, especially Candida albicans.

🦷To reduce this risk, clients should be taught to rinse the mouth or brush their teeth after each use of the inhaler.

💊Unlike systemic corticosteroids, inhaled versions typically cause localized rather than systemic side effects.

🧪Polyuria, hypoglycemia, and hypertension are not primary adverse effects of inhaled fluticasone.

📌Core Message

Inhaled corticosteroids like fluticasone may cause oral candidiasis, making oral hygiene essential after use.

Answer 8

Correct Answers:

Heparin

Rationale :

💉Heparin is the first-line medication used in the initial management of pulmonary embolism (PE) to prevent clot propagation.

🛑It acts quickly by enhancing the activity of antithrombin III, thereby inhibiting clotting factors and reducing the risk of further embolic events.

🫀PE is a life-threatening condition requiring immediate anticoagulation to reduce morbidity and mortality.

💊Other options like dexamethasone, furosemide, and atropine do not address the coagulopathy central to a PE.

📌Core Message

Heparin is the initial treatment of choice for pulmonary embolism due to its rapid anticoagulant effect.

Answer 9

Correct Answers:

"Well discard his toothbrush and buy another"

Rationale :

🪥Group A Streptococcus, the cause of streptococcal pharyngitis, can linger on personal items like toothbrushes and reinfect the client.

🧼Proper hygiene measures, including replacing contaminated items, are essential in preventing reinfection or spreading the illness.

💧While hydration and antipyretics are supportive measures, they do not address disease transmission.

🌡️Monitoring temperature is helpful, but it is not a preventive measure for disease spread.

📌Core Message

Preventing the spread of streptococcal infections includes discarding contaminated items like toothbrushes after treatment begins.

Answer 10

Correct Answers:

Need for suctioning.

Rationale :

🫁Following a total laryngectomy, airway management is the highest priority due to the loss of normal airway anatomy and the need for a tracheostomy for breathing.

🧹Secretions can accumulate rapidly in the airway postoperatively, and the inability to clear them without suctioning can lead to airway obstruction and hypoxia.

🚫While dressing integrity, pain level, and IV access are all important, they do not take precedence over airway clearance, which is critical to life.

🛑If secretions are not effectively suctioned, the client may experience respiratory distress or even respiratory arrest.

📌Core Message

After a total laryngectomy, ensuring airway patency through suctioning is the top priority due to altered anatomy and secretion buildup.

1 :
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

2 :
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?

3 :
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

4 :
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

5 :
A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include?

6 :
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

7 :
A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?

8 :
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

9 :
A nurse is providing teaching to the parents of a child who has streptococcal pharyngitis about ways to prevent disease transmission. Which of the following responses by the parents indicates an understanding of the teaching?

10 :
A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the clients care?

1 : A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

2 : A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?

3 : A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

4 : A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

5 : A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include?

6 : A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

7 : A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?

8 : A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

9 : A nurse is providing teaching to the parents of a child who has streptococcal pharyngitis about ways to prevent disease transmission. Which of the following responses by the parents indicates an understanding of the teaching?

10 : A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the clients care?

1 :
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

2 :
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?

3 :
A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

4 :
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

5 :
A nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include?

6 :
A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?

7 :
A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?

8 :
A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

9 :
A nurse is providing teaching to the parents of a child who has streptococcal pharyngitis about ways to prevent disease transmission. Which of the following responses by the parents indicates an understanding of the teaching?

10 :
A nurse is caring for a client following a total laryngectomy. Which of the following is the priority observation in the clients care?