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 C
Explanation
Choice A rationale
Administering diuretic medication as prescribed is an important intervention for managing fluid overload in heart failure. Diuretics help reduce fluid accumulation by increasing urine output, which can alleviate symptoms such as swelling and shortness of breath. However, before administering any medication, it is crucial to assess the client’s current respiratory status and oxygen saturation to determine the severity of their condition and ensure that the intervention is appropriate and safe.
Choice B rationale
Elevating the client’s legs can help reduce swelling in the lower extremities by promoting venous return and decreasing fluid accumulation. While this intervention can provide some relief, it does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Choice C rationale
Assessing the client’s respiratory status and oxygen saturation is the first priority in this scenario. Heart failure can lead to pulmonary congestion and impaired gas exchange, resulting in shortness of breath and decreased oxygen levels. By assessing the client’s respiratory status and oxygen saturation, the nurse can determine the severity of the client’s condition, identify any immediate respiratory needs, and implement appropriate interventions to improve oxygenation and respiratory function.
Choice D rationale
Restricting fluid intake is a common intervention for managing fluid overload in heart failure. By limiting fluid intake, the nurse can help prevent further fluid accumulation and reduce the risk of worsening symptoms. However, this intervention does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Correct Answer is A
Explanation
Choice A rationale
Administering antipyretic medication as prescribed is a priority intervention for a client with a body temperature of 38°C (100.4°F). Antipyretics help reduce fever and provide comfort to the patient. They work by inhibiting the production of prostaglandins, which are involved in the fever response.
Choice B rationale
Encouraging fluid intake to prevent dehydration is also important, but it is not the priority intervention. Adequate hydration helps maintain fluid balance and supports the body’s ability to regulate temperature.
Choice C rationale
Monitoring vital signs every 4 hours is essential for assessing the patient’s condition, but it is not an intervention that directly addresses the fever. It helps track the patient’s response to treatment and detect any changes in their condition.
Choice D rationale
Applying a cooling blanket to reduce fever can be effective, but it is typically used when antipyretic medications are not sufficient or contraindicated. Cooling measures help lower body temperature through conduction and evaporation.