Nokea
Which of the following statements are incorrect about discharge teaching that you would provide to a patient with COPD? Select-all-that-apply:
- A. It is best to eat three large meals a day that are relatively low in calories.'
- B. Avoid going outside during extremely hot or cold days.'
- C. It is important to receive the Pneumovax vaccine annually.'
- D. Smoking cessation can help improve your symptoms.'
Correct Answer: A,C
Rationale: Eating small, frequent meals (not three large meals, A) prevents diaphragm compression, and Pneumovax is not annual but given once or as per guidelines. Avoiding extreme weather and smoking cessation are correct.
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The client diagnosed with an exacerbation of COPD is in respiratory distress. Which intervention should the nurse implement first?
- A. Assist the client into a sitting position at 90 degrees.
- B. Administer oxygen at six (6) LPM via nasal cannula.
- C. Monitor vital signs with the client sitting upright.
- D. Notify the health-care provider about the client's status.
Correct Answer: A
Rationale: Sitting upright (A) improves lung expansion in COPD distress, a priority. Oxygen (B), vitals (C), and notification (D) follow to support oxygenation and communication.
Which isolation procedure should be instituted for the client admitted to rule out severe acute respiratory syndrome (SARS)?
- A. Airborne isolation.
- B. Droplet isolation.
- C. Reverse isolation.
- D. Strict isolation.
Correct Answer: A
Rationale: SARS is transmitted via respiratory droplets and possibly aerosols, requiring airborne isolation (A) with a negative pressure room and N95 masks. Droplet isolation (B) is insufficient for potential aerosol transmission. Reverse isolation (C) protects immunocompromised patients, not applicable here. Strict isolation (D) is not a standard term for SARS precautions.
After the bronchoscopy, what should the nurse closely monitor?
- A. The client's level of consciousness
- B. The client's oral status
- C. The client's respiratory effort
- D. The client's ability to speak
Correct Answer: C
Rationale: Monitoring respiratory effort is critical post-bronchoscopy to detect complications like airway obstruction or pneumothorax.
Which assessment finding noted by the nurse on the client's return to the room is an early indication that the client's oxygenation status is compromised?
- A. The client's dressing is bloody.
- B. The client appears restless.
- C. The client's heart rate is irregular.
- D. The client indicates feeling cold.
Correct Answer: B
Rationale: Restlessness is an early sign of hypoxia, indicating compromised oxygenation status, which requires immediate attention.
After administering morphine sulfate (Roxanol) to the client, which of the following is most important for the nurse to assess?
- A. The rhythm of the heart
- B. Skin color and temperature
- C. Presence of bowel sounds
- D. Rate and depth of respirations
Correct Answer: D
Rationale: Morphine can cause respiratory depression, so assessing the rate and depth of respirations is critical to ensure safety.