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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Custom Fall NS 126 Exam 1

No.

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.).

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Custom Fall NS 126 Exam 1

No.

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.).