5.1.5: FRAME 5- Take Action

CORRECT Answer

Question Type: Multiple Choice

Scoring: 0/1

NCSBN Item Type and Scoring: https://www.ncsbn.org/public-files/p...main_stage.pdf

What action will nurse take next?

1. Titrate down the Venturi mask
2. Begin education about the flutter valve and have the client try
3. Ask the client if he is up for a short walk in 15 minutes
4. Administer medications

RATIONALE

Stanley is showing signs of improvement, the nurse recognizes this by reviewing lab results, current vital signs, and client appearance and subjective assessment. The most appropriate action for the nurse to take is titrate down the Venturi mask to begin the weaning process from a higher oxygen device. It will be ideal for Stanley to be able to go back to a nasal cannula so he can begin flutter valve therapy, increase ambulation, and eat/drink better. By titrating down the oxygen therapy when the nurse is anticipated to be in the client’s room for medication pass, will allow the nurse to continuously monitor the client’s response to less O2 therapy.

FOCUSED GUIDE

To Maintain Airway Clearance	To Improve Breathing Patterns	To Improve Activity Intolerance
▪ Administer ordered bronchodilators and steroids ▪ Controlled coughing	▪ Diaphragmatic breathing ▪ Pursed-lip breathing ▪ Anxiety reducing measures	▪ Pace daily activities to maintain and support energy expenditure ▪ Exercise training ▪ Walking aids

It is important for students to recognize the positive impact nurses portray on clients with COPD through a variety of roles (hospital-based, community, palliative, respiratory). In general, each of these different nurse roles use different techniques when assisting clients with COPD. Techniques such as home telemonitoring, telecare, palliative care, health education, health training, oxygen management at home, self-efficacy, behavioral therapy and counseling, and smoking cessation techniques have all been utilized and found to be very effective. Furthermore, home visits can impact and decrease the number of readmissions, as well as improve the client’s confidence and knowledge in their disease management. Monitoring such as telemonitoring of vital parameters can help to reduce levels of anxiety and depression in clients with respiratory diseases (Aranburu-Imatz et al., 2022). The SDOH domain of Health Care Access & Quality focuses on getting people the health care services they need. Specifically, Stanley might benefit from the assistance of healthcare providers and nurses through the role of telehealth (AHS-R02). Healthy People 2030 is focused on increasing the use of telehealth to improve access to health services. This would allow Stanley to have access and resources from the comfort of his home to intervene early and prevent a respiratory exacerbation that would require hospitalization.