Nokea
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
- A. Assisting with all bathing and hygiene
- B. Telling the patient to avoid speaking during hygiene
- C. Teaching the patient to take short shallow breaths during activity
- D. Taking rest periods between activities
Correct Answer: D
Rationale: To prevent fatigue during activities including hygiene, the nurse should group (personal care) activities into smaller steps and encourage rest periods between activities. The nurse promotes and maintains dignity, independence, and strength by assisting with activities when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits and teach the patient to coordinate pursed-lip or diaphragmatic breathing with the activity.
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A nursing student attending clinical on a medical-surgical unit receives report from the off-going nurse stating the patient has adventitious breath sounds that clear after expectorating sputum. Which adventitious breath sound will the student expect to auscultate?
- A. Bronchial
- B. Bronchovesicular
- C. Vesicular
- D. Wheezing
Correct Answer: D
Rationale: Wheezing and crackles represent adventitious or abnormal breath sounds. Bronchial, bronchovesicular, and vesicular breath sounds are normal.
A nurse is maintaining airway patency in an unconscious patient by providing frequent nasopharyngeal suction. When would the nurse anticipate inserting a nasopharyngeal airway (nasal trumpet)?
- A. Vomiting during suctioning occurs.
- B. Secretions appear to contain stomach contents.
- C. The suction catheter touches an unsterile surface.
- D. Epistaxis is noted with continued suctioning.
Correct Answer: D
Rationale: Repeated suctioning may injure or traumatize the nares, resulting in nosebleed (epistaxis). The nurse would recommend insertion of a nasal trumpet, which will facilitate suction while protecting the nasal mucosa from further trauma.
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly?
- A. Making sure the oxygen is flowing into the prongs
- B. Maintaining oxygen saturation between 94% and 98%
- C. Encouraging the patient to breathe through their nose with their mouth closed
- D. Initiating the oxygen flow rate at 6 L/min or more
- E. Protecting the patient's skin from irritation by the oxygen tubing
Correct Answer: A,C,E
Rationale: The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should encourage the patient to breathe through their nose with the mouth closed. The nurse should adjust the flow rate and maintain the patient's oxygen saturation as prescribed. The nurse should implement pressure injury prevention strategies; pressure from the tubing could result in medical device-related alterations in skin integrity.
A nurse working in the pulmonary clinic is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend?
- A. Avoid exercise.
- B. Take steps to manage or reduce anxiety.
- C. Eat meals 1 to 2 hours prior to breathing treatments.
- D. Eat a high-protein/high-calorie diet.
- E. Maintain a high-Fowler position when possible.
- F. Drink 2 to 3 pints of clear fluids daily.
Correct Answer: B,D,E
Rationale: When caring for patients with COPD, it is important to help create an environment that is likely to reduce anxiety, which increases oxygen demand. A high-protein/high-calorie diet is recommended to meet increased energy needs due to the work of breathing. People with dyspnea and orthopnea are most comfortable in a high-Fowler (upright) position because accessory muscles can easily be used to facilitate respiration and lung expansion. Meals should be eaten 1 to 2 hours after breathing treatments; exercise and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended, rather than 2 to 3 pints.
A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first?
- A. Place the patient in Fowler position.
- B. Encourage diaphragmatic breathing.
- C. Ask the patient to cough.
- D. Initiate oral suctioning of secretions.
Correct Answer: A
Rationale: Patients with COPD experience dyspnea related to problems with ventilation and/or hypoxemia. One of the most common symptoms of hypoxia is dyspnea (difficulty breathing). Elevating the head of the bed will improve respiratory expansion and oxygenation. Coughing to facilitate secretion removal, pursed-lip breathing, and/or diaphragmatic breathing may be indicated, after sitting the patient up. Suction is indicated for patients demonstrating the presence of secretions, such as adventitious breath sounds or moist cough with phlegm; there is no indication this patient requires suctioning at this time.