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Difficulty: MediumBasic Care and Comfort

A client with severe chronic obstructive pulmonary disease (COPD) and right-sided heart failure (cor pulmonale) is receiving treatment for acute respiratory distress and massive lower extremity edema. The client requires assistance with all activities of daily living. Which nursing actions appropriately address the client's basic care and comfort needs? Select all that apply.

  1. Provide frequent, small meals that are high in calories and easy to chewAnswer
  2. Suspend the client's heels off the bed by placing a supportive cushion under the calvesAnswer
  3. C
    Elevate the legs by placing a firm bolster directly beneath the popliteal space
  4. Offer oral hygiene with a soft toothbrush and non-alcohol-based mouthwash every few hoursAnswer
  5. E
    Delegate the auscultation of lung sounds before and after hygiene tasks to the unlicensed assistive personnel
  6. F
    Attribute the sudden onset of lethargy and confusion to expected cognitive decline from normal aging

Answer

The correct interventions are providing frequent small meals, suspending the heels off the bed, and offering regular oral hygiene.
Providing small, high-calorie meals reduces the energy required for eating and digestion, which is crucial for clients with severe respiratory distress. Suspending the heels relieves pressure on edematous, vulnerable tissues, preventing pressure injuries. Frequent oral hygiene with non-alcohol-based products keeps mucous membranes moist and comfortable, especially for clients breathing through their mouths or receiving oxygen therapy.

Step-by-Step Solution

1
Analyze the client's physiological needs related to severe COPD, cor pulmonale, and peripheral edema.
The client requires energy conservation, pressure relief for edematous extremities, and mucous membrane care.
Systemic fluid overload and respiratory distress significantly increase metabolic demands and the risk of skin breakdown.
2
Evaluate each intervention against basic care standards and safety protocols for this specific condition.
Nutritional support via small meals, pressure relief via heel suspension, and regular oral care are identified as safe and effective.
These actions directly promote comfort and hygiene without compromising respiratory or circulatory function.
3
Identify contraindicated actions in the remaining options.
Popliteal pressure, delegating assessments, and ignoring neurological changes are recognized as unsafe practices.
These actions violate positioning guidelines, delegation rules, and pathophysiology principles.

Key Concept

Basic care and comfort for clients with severe cardiopulmonary compromise involves energy conservation, skin integrity maintenance, and recognizing acute physiological changes over normal aging.
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Topics

Basic Care and Comfort

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