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 B
Explanation
Choice A rationale
Checking blood sugar levels before each meal is a good practice for managing diabetes and does not indicate a need for further teaching.
Choice B rationale
Skipping medication if blood sugar is normal indicates a misunderstanding of diabetes management. Medications should be taken as prescribed to maintain consistent blood sugar levels.
Choice C rationale
Following a balanced diet and exercising regularly are important components of diabetes management and do not indicate a need for further teaching.
Choice D rationale
Monitoring feet for cuts or sores is crucial for diabetes management to prevent complications like infections and ulcers.
Correct Answer is C
Explanation
Choice A rationale
Hyperkalemia can cause weakness and fatigue, but it is not directly related to acute coronary syndrome (ACS). ACS is primarily associated with chest pain and other cardiac symptoms.
Choice B rationale
Experiencing chest pain when climbing a flight of stairs may indicate stable angina, which is a form of chronic coronary artery disease. However, it does not meet the criteria for ACS, which involves more severe and persistent symptoms.
Choice C rationale
Persistent and severe chest pain when at rest is a hallmark symptom of acute coronary syndrome (ACS). This condition requires immediate medical attention as it can lead to myocardial infarction (heart attack) or other serious complications.
Choice D rationale
Paroxysmal nocturnal dyspnea (PND) is a symptom of heart failure, not acute coronary syndrome (ACS). While heart failure can coexist with ACS, PND alone does not indicate ACS4.