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The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who has a nursing diagnosis of imbalanced nutrition: less than body requirements. Which of the following interventions is best to address this problem?
- A. Increase the patient's intake of fruits and fruit juices.
- B. Have the patient exercise for 10 minutes before meals.
- C. Assist the patient in choosing foods with a lot of texture.
- D. Offer high calorie snacks between meals and at bedtime.
Correct Answer: D
Rationale: Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice.
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The nurse is caring for a patient in the emergency department who is experiencing an acute asthma attack. After listening to the patient's breath sounds, which of the following should the nurse take next?
- A. Start an intravenous with Ringer's Lactate.
- B. Ask about inhaled corticosteroid use.
- C. Determine when the dyspnea started.
- D. Obtain a peak expiratory flow rate (PEFR).
Correct Answer: D
Rationale: The examiner can assess the degree of severity by measuring FEV1 or PEFR, identifying the degree of change in objective measurements, and evaluating the baseline pulse oximetry value. The length of time the attack has persisted is not as important as determining the patient's status at present. It is important to know about the medications the patient is using but not as important as assessing the breath sounds. Initiating IV therapy is not a priority at this time.
Which of the following findings by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment?
- A. Pulse oximetry reading of 91.9%.
- B. Absence of wheezes or crackles.
- C. Decreased use of accessory muscles.
- D. Respiratory rate of 22 breaths/minute.
Correct Answer: A
Rationale: For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen through a Venturi mask. Which of the following actions should the nurse take?
- A. Ensure that the oxygen flow is at least 10 L/min.
- B. Keep the air entrainment ports free of obstruction.
- C. Attach a humidifier to the oxygen delivery system.
- D. Drain condensation from the oxygen tubing every hour.
Correct Answer: B
Rationale: The air entrainment ports regulate the oxygen percentage delivered to the patient, so they must be unobstructed. A high oxygen flow rate is needed when giving oxygen by partial rebreather or nonrebreather masks. The use of an adaptor can improve humidification but not oxygen delivery. Draining oxygen tubing is necessary when caring for a patient receiving mechanical ventilation.
The nurse is evaluating the effectiveness of therapy for a patient who has received treatment during an asthma attack. Which of the following findings is the best indicator that the therapy has been effective?
- A. No wheezes are audible.
- B. Oxygen saturation is >95%.
- C. Accessory muscle use has decreased.
- D. Respiratory rate is 16 breaths/minute.
Correct Answer: B
Rationale: The goal for treatment of an asthma attack is to keep the oxygen saturation >92%. The other patient data may occur when the patient is too fatigued to continue with the increased work of breathing required in an asthma attack.
A young adult patient with cystic fibrosis (CF) tells the nurse that she is considering having a child. Which of the following responses is best for the nurse to respond initially?
- A. Are you aware of the normal lifespan for patients with CF?'
- B. Do you need any information to help you with the decision?'
- C. You will need to have genetic counselling before making a decision.'
- D. Many women with CF do not have difficulty in conceiving children.'
Correct Answer: B
Rationale: The nurse's initial response should be to assess the patient's knowledge level and need for information. Although the lifespan for patients with CF is likely to be shorter than normal, it would not be appropriate for the nurse to address this as the initial response to the patient's comments. The other responses are accurate, but the nurse should first assess the patient's understanding about the issues surrounding pregnancy.