NCLEX-PN

Category - Basic Care

A nurse is caring for a client with emphysema. Which of the following interventions is the priority of the nurse when caring for the client?
  1. Reinforce deep diaphragmatic breathing and pursed-lip breathing
  2. Maintain the client’s fluid intake to no less than 1500 mL per day
  3. Maintain oxygen flow rate at 2 L/min
  4. Offer foods high in carbohydrate and protein
Explanation
Answer: C - The priority of the nurse is to maintain the oxygen flow rate between 1 and 2 L/min. Clients with emphysema are stimulated by low partial pressure of oxygen to breathe, instead of increasing partial pressure of carbon dioxide. The other interventions are appropriate, but they are not the nurse’s priority.
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