A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with increased shortness of breath and a productive cough. The nurse notes the client’s oxygen saturation is 88% on room air. Which of the following interventions should the nurse implement first?
Administering supplemental oxygen.
Encouraging the client to use an incentive spirometer.
Administering a bronchodilator as prescribed.
Positioning the client in high Fowler’s position.
The Correct Answer is A
Choice A rationale
Administering supplemental oxygen is the priority intervention for a client with COPD who has an oxygen saturation of 88% on room air. This low oxygen saturation indicates hypoxemia, which requires immediate correction to prevent further respiratory distress.
Choice B rationale
Encouraging the client to use an incentive spirometer is important for lung expansion and preventing atelectasis, but it is not the priority intervention in this scenario. The immediate concern is to correct the hypoxemia.
Choice C rationale
Administering a bronchodilator as prescribed is important for managing COPD symptoms, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.
Choice D rationale
Positioning the client in high Fowler’s position can help improve breathing, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.
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Correct Answer is D
Explanation
Choice A rationale
Cerebral edema is the swelling of the brain due to fluid accumulation, which can occur after excessive alcohol consumption. However, it is not related to myxedema, which is a condition associated with severe hypothyroidism.
Choice B rationale
The deposit of fatty tissue is associated with conditions like hyperaldosteronism, where there is an excess production of aldosterone. This condition does not cause the characteristic skin changes seen in myxedema.
Choice C rationale
Proliferation of tissue behind the eyes, known as exophthalmos, is common in hyperthyroidism, particularly in Graves’ disease. Myxedema, on the other hand, is related to severe hypothyroidism and involves different pathophysiological mechanisms.
Choice D rationale
Myxedema is characterized by the accumulation of mucopolysaccharides in the skin and other tissues, leading to swelling and thickening of the skin. This condition is a result of severe hypothyroidism and can lead to a myxedema crisis if left untreated.
Correct Answer is ["A","B","E","F"]
Explanation
Choice A rationale
The tripod position helps to improve breathing by allowing the diaphragm to expand more effectively. This position reduces the work of breathing and helps to increase lung capacity, which is beneficial for patients with emphysema.
Choice B rationale
Pursed lip breathing is a technique that helps to keep the airways open longer, allowing more air to escape and reducing the work of breathing. This method helps to improve ventilation and oxygenation in patients with emphysema.
Choice C rationale
Staying current with yearly vaccinations is important for overall health, but it is not a specific strategy for better breathing in emphysema patients. Vaccinations help prevent respiratory infections, which can exacerbate emphysema symptoms.
Choice D rationale
Taking an antihistamine every day is not a recommended strategy for better breathing in emphysema patients. Antihistamines are typically used to treat allergies and may have side effects that could worsen breathing difficulties.
Choice E rationale
Inhaling slowly and deeply helps to maximize lung expansion and improve oxygenation. This technique can help to reduce shortness of breath and improve overall breathing efficiency in patients with emphysema.
Choice F rationale
Sleeping with 2 pillows to prop oneself up helps to reduce the work of breathing by preventing the diaphragm from being compressed. This position can help to improve breathing and reduce shortness of breath during sleep.
Choice G rationale
Measuring peak flow is a useful tool for monitoring lung function, but it is not a specific strategy for better breathing in emphysema patients. Peak flow measurements can help to track the progression of the disease and adjust treatment plans accordingly.
Choice H rationale
Taking a leukotriene inhibitor every day is not a recommended strategy for better breathing in emphysema patients. Leukotriene inhibitors are typically used to treat asthma and may not be effective for emphysema.