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 A
Explanation
Choice A rationale
Severe headache and photophobia are classic symptoms of meningitis, indicating inflammation of the meninges.
Choice B rationale
Chest pain and shortness of breath are more indicative of cardiovascular or respiratory issues, not meningitis.
Choice C rationale
Abdominal pain and diarrhea are gastrointestinal symptoms and are not typically associated with meningitis.
Choice D rationale
Joint pain and swelling are more indicative of rheumatologic conditions, not meningitis.
Correct Answer is A
Explanation
Choice A rationale
Septic shock is characterized by a systemic inflammatory response to infection, leading to vasodilation, increased capillary permeability, and hypotension. The patient’s elevated temperature, tachycardia, and hypotension are consistent with septic shock. In septic shock, the body’s response to infection leads to widespread inflammation and impaired tissue perfusion.
Choice B rationale
Hypovolemic shock is caused by a significant loss of blood or fluids, leading to decreased circulating volume and hypotension. While the patient’s hypotension and tachycardia could be consistent with hypovolemic shock, the elevated temperature suggests an infectious process, making septic shock more likely.
Choice C rationale
Cardiogenic shock is caused by the heart’s inability to pump effectively, leading to decreased cardiac output and tissue perfusion. While hypotension and tachycardia are consistent with cardiogenic shock, the elevated temperature is not a typical finding. Cardiogenic shock is usually associated with conditions like myocardial infarction or severe heart failure.
Choice D rationale
Neurogenic shock is caused by a disruption in the autonomic pathways, leading to vasodilation and hypotension. It is typically associated with spinal cord injuries or severe head trauma. The patient’s elevated temperature and tachycardia are not consistent with neurogenic shock, making septic shock the more likely diagnosis.