26.The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing?a.Sitting up and leaning on a tableb.Standing and leaning against a wallc.Lying on the back in a low Fowler's positiond.Sitting up with the elbows resting on the kneesRationale:The client should not lie on the back because this reduces movement of a large area of the client's chest wall. The client should use positions that allow for maximal chest expansion. Sitting, if possible, is better than standing. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and notfor posture control.27.The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB?Select all that apply.28.The nurse is reading a tuberculin skin test for a client with no documented healthproblems. The site has no induration and a 1-mm area of ecchymosis. How should the nurse interpret the result?
29.A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism?30.The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2level is 86%. Based on this assessment, which action is appropriate?a.Increase to 3 L/min and titrate until the SpO2is 95%.b.Increase to 3 L/min and titrate until the SpO2is 88%c.Place the client on a nonrebreather mask on 100% FiO2.d.Maintain at 2 L/min and call respiratory therapy for a breathing treatment.Rationale:Oxygen is used cautiously and should be titrated to the lowest amount needed; however, clients with obstructive lung disease were once thought to be at risk for hypoventilation with oxygen because of the decreased respiratory drive as a result of increased oxygen blood levels. Research has not supported this position, and the current recommendation is that hypoxia should be treated with oxygen and that oxygenshould be titrated to keep the SpO2level between 88% and 92%. An SpO2of 95% is the recommended level for a healthy individual; therefore, option 1 is incorrect. A nonrebreather mask is not necessary at this point, and oxygen via nasal cannula should be attempted first; therefore, option 3 is incorrect. It may be necessary to call respiratory therapy for a breathing treatment; however, the oxygen needs to be titrated,making option 4 incorrect.
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- Summer '18
- pulmonary disease