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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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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Administering sodium polystyrene sulfonate helps to lower potassium levels by exchanging sodium ions for potassium ions in the intestines. However, it is not the first intervention because it takes time to work and does not address the immediate risk of cardiac arrhythmias caused by hyperkalemia.

Choice B rationale

Monitoring the client’s cardiac rhythm is the first intervention because hyperkalemia can cause life-threatening cardiac arrhythmias. Continuous cardiac monitoring allows for the early detection and treatment of these arrhythmias, which is crucial for the client’s safety.

Choice C rationale

Restricting dietary potassium intake is an important long-term management strategy for hyperkalemia, especially in clients with chronic kidney disease. However, it does not address the immediate risk of cardiac arrhythmias and is not the first intervention.

Choice D rationale

Preparing the client for hemodialysis is a definitive treatment for hyperkalemia, especially in clients with chronic kidney disease. However, it is not the first intervention because it takes time to arrange and initiate dialysis. Immediate cardiac monitoring is necessary to manage the acute risk of arrhythmias.

Correct Answer is A

Explanation

Choice A rationale

Acute pancreatitis is characterized by severe epigastric pain and elevated levels of amylase and lipase. These enzymes are released into the bloodstream when the pancreas is inflamed, making acute pancreatitis the most likely diagnosis.

Choice B rationale

Acute hematochezia refers to the passage of fresh blood through the anus, usually in or with stools. It is not associated with elevated amylase and lipase levels or severe epigastric pain.

Choice C rationale

Left heart failure can cause symptoms such as shortness of breath and fluid retention, but it does not typically cause elevated amylase and lipase levels or severe epigastric pain.

Choice D rationale

Chronic hepatic failure involves long-term liver damage and may present with jaundice, ascites, and other symptoms. It is not associated with elevated amylase and lipase levels or severe epigastric pain.

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