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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?

 

A.

Administering supplemental oxygen.

B.

Encouraging the client to use an incentive spirometer.

C.

Administering a bronchodilator as prescribed.

D.

Positioning the client in high Fowler’s position.

Answer and Explanation

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

Wearing an N95 mask is appropriate for airborne precautions, such as tuberculosis, but not specifically for MRSA, which requires contact precautions.

Choice B rationale

Wearing a facemask is suitable for droplet precautions, such as influenza, but MRSA is primarily spread through direct contact, not droplets.

Choice C rationale

Using a separate disposable blood pressure cuff for patients with draining wounds helps prevent the spread of MRSA. MRSA can be transmitted via contaminated medical equipment.

Choice D rationale

Strict hand washing measures are essential but should be performed more frequently than once every 8-hour shift. Hand hygiene should be practiced before and after patient contact.

Correct Answer is A

Explanation

Choice A rationale

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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.

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