Question

A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

Answer 1

Correct Answers:

Instruct the client to use pursed-lip breathing.

Rationale :

🔹 Pursed-lip breathing is a key intervention for clients with chronic obstructive pulmonary disease (COPD).

🔹 It helps to prolong exhalation, which prevents air trapping, improves oxygenation, and promotes more effective breathing patterns.

🔹 This technique also reduces dyspnea, promotes carbon dioxide elimination, and gives the client a sense of better breathing control.

🔹 It is especially useful during episodes of exertional breathlessness or anxiety.

🔹 Teaching this method is a fundamental component of pulmonary rehabilitation and self-management for COPD.

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Answer 2

Correct Answers:

Bananas.

Rationale :

🔹 Furosemide is a loop diuretic that promotes renal excretion of potassium, placing clients at risk for hypokalemia.

🔹 A potassium level of 3.1 mEq/L is below the normal range (3.5–5.0 mEq/L) and requires dietary correction or supplementation.

🔹 Bananas are a rich source of potassium, making them ideal for clients needing to increase their serum potassium levels.

🔹 Other potassium-rich foods include oranges, spinach, sweet potatoes, tomatoes, and avocados, but bananas are among the most accessible and commonly recommended.

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Answer 3

Correct Answers:

Apply the client's positive airway pressure device.

Rationale :

✴️ Maintains airway patency: Positive airway pressure (PAP) devices like CPAP or BiPAP prevent airway collapse during sleep, which is critical for clients with obstructive sleep apnea (OSA).

✴️ Prevents hypoxia: Clients with OSA are at risk for repeated apnea episodes, leading to oxygen desaturation and potential complications such as cardiac arrhythmias or respiratory arrest.

✴️ Essential after sedation: Medications like acetaminophen can cause drowsiness, increasing the risk of airway obstruction in OSA clients. Ensuring the PAP device is applied before the client dozes off is crucial.

✴️ Improves sleep quality and safety: PAP devices not only ensure adequate ventilation but also help reduce nocturnal awakenings, snoring, and associated daytime fatigue, promoting better recovery.

✴️ Prevention of adverse outcomes: Failure to apply the PAP device could result in respiratory compromise, especially if the client becomes sedated or lies supine without airway support.

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Answer 4

Correct Answers:

Place restrictions on visitation.

Rationale :

🚷 Reduces introduction of new infections: Visitors can unknowingly carry and transmit the influenza virus into the facility, placing already vulnerable residents at increased risk.

🚷 Protects high-risk residents: Long-term care clients, particularly the elderly or chronically ill, are at high risk for severe influenza complications, including pneumonia or death.

🚷 Supports outbreak containment: Limiting visitation is a core infection control measure that helps minimize the spread of illness within healthcare environments.

🚷 Recommended by health authorities: Organizations like the CDC recommend limiting visitors as part of standard protocols during confirmed influenza outbreaks in communal settings.

🚷 Buys time for further action: Restricting visitors allows healthcare teams to stabilize the outbreak, implement antiviral treatment or prophylaxis, and reinforce standard and droplet precautions.

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Answer 5

Correct Answers:

Breathe in through her nose and out through pursed lips.

Rationale :

💫 Improves gas exchange: Pursed-lip breathing prolongs exhalation, which helps to expel trapped air in the alveoli—common in emphysema due to air trapping and loss of lung elasticity.

💫 Reduces dyspnea: This technique helps regulate breathing and decreases the work of breathing, making it easier for clients to breathe, especially during exertion.

💫 Promotes oxygenation and CO₂ clearance: By keeping the airways open longer during exhalation, pursed-lip breathing enhances alveolar ventilation and prevents CO₂ buildup.

💫 Provides client control: It gives clients a simple, effective tool to manage episodes of breathlessness and reduces anxiety associated with difficulty breathing.

💫 Essential in COPD care: This is a core part of pulmonary rehabilitation and is especially vital for clients with emphysema, a form of COPD characterized by alveolar damage and reduced surface area for gas exchange.

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Answer 6

Correct Answers:

Low BP and high pulse rate.

Rationale :

🩸 Low blood pressure (hypotension): In hypovolemic shock, there is a significant loss of circulating blood volume due to bleeding, dehydration, or third-spacing. As volume decreases, cardiac output drops, leading to reduced perfusion and hypotension.

🩸 High pulse rate (tachycardia): To compensate for falling blood pressure and perfusion, the body increases heart rate. This sympathetic response attempts to maintain oxygen delivery to vital organs by boosting cardiac output.

🩸 This combination—hypotension with compensatory tachycardia—is one of the earliest and most recognizable signs of hypovolemic shock.

🩸 Additional signs may include cool, clammy skin, delayed capillary refill, decreased urine output, and altered mental status, all stemming from reduced perfusion.

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Answer 7

Correct Answers:

Dyspnea.
Clubbing of the fingers.
Barrel chest.
Shallow respirations.

Rationale :

✅ A. Dyspnea

🌬️ Progressive breathlessness is a hallmark of emphysema due to destruction of alveolar walls, which reduces the lungs’ ability to perform effective gas exchange.

🌬️ Clients often describe difficulty breathing, especially during physical exertion, as trapped air builds up and makes full exhalation difficult.

🌬️ This symptom worsens over time, eventually occurring even at rest in advanced stages of the disease.

✅ C. Clubbing of the fingers

☁️ Clubbing is a rounded, bulbous enlargement of the fingertips and is commonly associated with chronic hypoxia.

☁️ Emphysema leads to long-term oxygen deprivation, triggering changes in the capillaries of the nail beds and soft tissues of the fingers.

☁️ This is an adaptive response to persistently low oxygen levels and often indicates advanced lung disease.

✅ D. Barrel chest

🫁 A barrel chest is the result of chronic lung overexpansion, which increases the anterior-posterior diameter of the chest.

🫁 In emphysema, trapped air stretches the lungs and forces the chest wall to stay expanded, even during exhalation.

🫁 This physical change gives the chest a rounded, barrel-like appearance and reflects the loss of lung elasticity.

✅ E. Shallow respirations

💨 Clients with emphysema often breathe using shallow, rapid respirations to compensate for the reduced surface area for oxygen exchange.

💨 The damaged lungs cannot fully expel air, so breathing becomes quicker and less efficient.

💨 Clients may use accessory muscles (neck, shoulders) to assist with breathing, especially during episodes of dyspnea.

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Answer 8

Correct Answers:

Orthopnea.
Dyspnea.

Rationale :

✅ D. Orthopnea

🌙 Orthopnea is difficulty breathing when lying flat, and it is a classic symptom of left-sided heart failure.

🌙 In this condition, the left ventricle fails to pump blood effectively, causing a backup of fluid into the pulmonary circulation.

🌙 When the client lies down, venous return increases, and the congested left heart cannot handle the volume, leading to pulmonary congestion and difficulty breathing.

🌙 Clients often need to sleep propped up on pillows or in a recliner to relieve this symptom and improve lung expansion.

✅ E. Dyspnea

💨 Dyspnea, or shortness of breath, is one of the most common and early symptoms of left-sided heart failure.

💨 It results from pulmonary congestion as the failing left ventricle cannot effectively move oxygenated blood forward into systemic circulation.

💨 This leads to fluid accumulation in the lungs (pulmonary edema), reducing gas exchange and causing labored breathing.

💨 Dyspnea may initially occur with exertion and progress to dyspnea at rest as the condition worsens.

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Answer 9

Correct Answers:

Decreased level of consciousness.

Rationale :

🧠 A sodium level of 155 mEq/L indicates hypernatremia (normal range: 135–145 mEq/L), which causes cellular dehydration, especially affecting neurons.

🧠 As sodium concentration increases in the extracellular fluid, water moves out of brain cells, leading to shrinkage of neurons and neurological dysfunction.

🧠 Clients may present with confusion, restlessness, irritability, and in severe cases, a decreased level of consciousness, seizures, or coma.

🧠 Hypernatremia is often due to water loss (e.g., dehydration, fever, diaphoresis) or sodium gain, and neurological symptoms are the most serious concern.

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Answer 10

Correct Answers:

The medication will open the airways.
The medication will prevent wheezing.
The medication will decrease coughing episodes.

Rationale :

✅ B. The medication will open the airways

🌬️ Albuterol is a short-acting beta2-adrenergic agonist (SABA) that works by relaxing the smooth muscles of the bronchi.

🌬️ This causes bronchodilation, which opens the airways and improves airflow, making it easier to breathe.

🌬️ It is especially useful during acute asthma attacks or before exercise to prevent bronchospasm.

✅ C. The medication will prevent wheezing

🔊 By relieving bronchoconstriction, albuterol reduces the turbulent airflow that causes wheezing.

🔊 When used as prescribed, it helps prevent or minimize wheezing episodes, especially in response to triggers like allergens, exercise, or cold air.

🔊 This helps improve the client’s respiratory comfort and function.

✅ E. The medication will decrease coughing episodes

💨 Coughing in asthma often results from airway narrowing and irritation.

💨 By opening the airways, albuterol reduces bronchospasm, which can significantly decrease coughing related to asthma.

💨 It helps break the cycle of cough-bronchospasm-cough, especially during acute episodes.

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QLexNursing

1 :
A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

2 :
A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet?

3 :
The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

4 :
A nurse is assisting with planning interventions for an influenza outbreak in a long-term care facility. Which of the following interventions should the nurse include in the plan?

5 :
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

6 :
A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?

7 :
A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.).

8 :
A nurse is preparing to administer digoxin to a client who has left-sided heart failure. Which of the following clinical manifestations should the nurse expect to see in this client? (Select all that apply.).

9 :
A nurse is collecting data from a client who has a sodium level of 155 mEq/L. Which of the following manifestations should the nurse expect?

10 :
A nurse is caring for a client who has asthma. The client asks the nurse how albuterol helps his breathing. Which of the following information should the nurse include in the response? (Select all that apply.).

QLexNursing

1 : A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

2 : A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet?

3 : The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

4 : A nurse is assisting with planning interventions for an influenza outbreak in a long-term care facility. Which of the following interventions should the nurse include in the plan?

5 : A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

6 : A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?

7 : A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.).

8 : A nurse is preparing to administer digoxin to a client who has left-sided heart failure. Which of the following clinical manifestations should the nurse expect to see in this client? (Select all that apply.).

9 : A nurse is collecting data from a client who has a sodium level of 155 mEq/L. Which of the following manifestations should the nurse expect?

10 : A nurse is caring for a client who has asthma. The client asks the nurse how albuterol helps his breathing. Which of the following information should the nurse include in the response? (Select all that apply.).

1 :
A nurse is contributing to the plan of care for a client who has COPD. Which of the following interventions should the nurse include in the plan of care?

2 :
A nurse is reinforcing teaching with a client who takes furosemide and has a serum potassium level of 3.1 mEq/L. Which of the following foods should the nurse instruct the client to include in his daily diet?

3 :
The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

4 :
A nurse is assisting with planning interventions for an influenza outbreak in a long-term care facility. Which of the following interventions should the nurse include in the plan?

5 :
A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema. Which of the following instructions should be included in the teaching?

6 :
A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?

7 :
A nurse is collecting data from a client who has emphysema. Which of the following findings should the nurse expect? (Select all that apply.).

8 :
A nurse is preparing to administer digoxin to a client who has left-sided heart failure. Which of the following clinical manifestations should the nurse expect to see in this client? (Select all that apply.).

9 :
A nurse is collecting data from a client who has a sodium level of 155 mEq/L. Which of the following manifestations should the nurse expect?

10 :
A nurse is caring for a client who has asthma. The client asks the nurse how albuterol helps his breathing. Which of the following information should the nurse include in the response? (Select all that apply.).