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Difficulty: MediumBasic Care and Comfort

A nurse is creating a plan of care for a newly admitted client experiencing an acute exacerbation of chronic obstructive pulmonary disease (COPD) accompanied by severe dyspnea, orthopnea, and profound fatigue. Which interventions should the nurse include to address the client's basic care and comfort? Select all that apply.

  1. Position the client leaning forward with their arms resting on a raised overbed tableAnswer
  2. Provide small, nutrient-dense meals that require minimal effort to chewAnswer
  3. C
    Maintain the client in a flat, supine position during the night to promote restorative sleep
  4. D
    Instruct the unlicensed assistive personnel (UAP) to perform the initial evaluation of the client's skin integrity
  5. E
    Apply bilateral soft wrist restraints if the client exhibits sudden agitation to prevent removal of the oxygen cannula

Answer

The correct interventions are positioning the client leaning forward over an overbed table and providing small, nutrient-dense meals that require minimal chewing.
Positioning the client leaning forward over an overbed table (orthopneic position) allows the accessory muscles of respiration to function more effectively, facilitating maximum chest expansion and easing dyspnea. Providing small, easily chewed meals prevents the client from expending excessive energy during eating, thereby reducing oxygen demand and minimizing severe fatigue.

Step-by-Step Solution

1
Identify the client's primary physiological challenges based on the clinical presentation.
The client is experiencing severe dyspnea, orthopnea, and fatigue secondary to a COPD exacerbation.
Understanding the underlying pathology is necessary to select appropriate comfort and basic care interventions.
2
Evaluate the proposed positioning and nutritional interventions for safety and efficacy.
Leaning forward on an overbed table maximizes chest expansion, while small, easy-to-chew meals conserve the client's limited energy.
These actions directly address the client's work of breathing and high risk for exhaustion.
3
Identify contraindicated actions or safety violations among the distractors.
Supine positioning, delegating an initial assessment to a UAP, and applying restraints for hypoxia-induced agitation are incorrect and potentially harmful.
These choices violate physiological safety principles, nursing scope of practice, and standard restraint protocols.

Key Concept

Basic care, comfort, and positioning for clients with respiratory compromise
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Topics

Basic Care and Comfort

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