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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 D

Explanation

Choice A rationale

Acute respiratory distress syndrome (ARDS) is characterized by severe hypoxemia and respiratory distress, often requiring mechanical ventilation. It is not typically associated with a mild fever and increased respiratory rate.

Choice B rationale

Chronic obstructive pulmonary disease (COPD) is a chronic condition characterized by airflow limitation and respiratory symptoms, but not typically associated with a mild fever.

Choice C rationale

Pulmonary edema involves fluid accumulation in the lungs, leading to respiratory distress and hypoxemia, but not typically associated with a mild fever.

Choice D rationale

Pneumonia is an infection of the lungs causing fever (37.5°C), increased respiratory rate (28 breaths per minute), and other respiratory symptoms. It is the most likely condition given the symptoms.

Correct Answer is A

Explanation

Choice A rationale

Increased shortness of breath is a key symptom of worsening congestive heart failure (CHF). It indicates that the heart is not effectively pumping blood, leading to fluid buildup in the lungs and increased respiratory effort.

Choice B rationale

A temperature of 37°C (98.6°F) is within the normal range and does not indicate worsening CHF. Monitoring the patient’s temperature is important, but it is not a sign of CHF exacerbation.

Choice C rationale

A blood pressure of 120/80 mmHg is within the normal range and does not indicate worsening CHF. Blood pressure should be monitored, but this reading does not suggest an acute issue.

Choice D rationale

Occasional dizziness can be a symptom of many conditions, including CHF, but it is not as specific or critical as increased shortness of breath. It should be monitored, but it does not indicate an immediate worsening of CHF.

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