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
Poor blood glucose control is a significant factor in delayed wound healing in patients with diabetes. Hyperglycemia impairs various aspects of the immune response, reduces blood flow, and increases the risk of infection, all of which contribute to delayed healing.
Choice B rationale
Inadequate protein intake can also contribute to delayed wound healing. Protein is essential for the repair and regeneration of tissues, and a deficiency can impair the body’s ability to heal wounds effectively.
Choice C rationale
Peripheral neuropathy, a common complication of diabetes, can lead to decreased sensation in the feet, making it more likely for injuries to go unnoticed and untreated. This can result in chronic wounds and delayed healing.
Choice D rationale
All of the above factors—poor blood glucose control, inadequate protein intake, and peripheral neuropathy—can contribute to delayed healing of foot ulcers in patients with diabetes. Each of these factors plays a role in the complex process of wound healing and can hinder the body’s ability to repair itself.
Correct Answer is A
Explanation
Choice A rationale
Bacterial infection often leads to an elevated white blood cell count (15,000/mm³) and fever (38.5°C). The body’s immune response to bacterial pathogens results in these clinical manifestations.
Choice B rationale
Viral infections can cause fever, but they typically do not lead to a significant increase in white blood cell count.
Choice C rationale
Fungal infections can cause fever and elevated white blood cell count, but they are less common and usually occur in immunocompromised individuals.
Choice D rationale
Parasitic infections can cause fever and elevated white blood cell count, but they are less common and usually present with other specific symptoms.