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The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

A.

Attach humidification to oxygen delivery.

B.

Coach through using huff coughing.

C.

Obtain a pulse oximetry reading.

D.

Provide nebulizer breathing treatment.

Answer and Explanation

The Correct Answer is C

Choice A rationale

 

Attaching humidification to oxygen delivery can help with comfort but is not the immediate priority in assessing the client’s respiratory status.

 

Choice B rationale

 

Coaching through using huff coughing is a useful technique for clearing secretions but should follow the assessment of the client’s oxygenation status.

 

Choice C rationale

 

Obtaining a pulse oximetry reading is the next immediate action after positioning the client upright. It provides essential information about the client’s oxygen saturation and helps guide further interventions.

 

Choice D rationale

 

Providing a nebulizer breathing treatment can help relieve symptoms but should be based on the assessment of the client’s oxygenation status.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Autoimmune response is not the correct type of immune reaction for a bee sting. Autoimmune responses involve the body’s immune system attacking its own tissues, which is not the case with bee stings.

Choice B rationale

IgE response hypersensitivity is the correct type of immune reaction for a bee sting. Bee stings can trigger an IgE-mediated hypersensitivity reaction, leading to symptoms such as rash, difficulty breathing, and low blood pressure. This type of reaction is also known as anaphylaxis.

Choice C rationale

Cell-mediated hypersensitivity is not the correct type of immune reaction for a bee sting. Cell-mediated hypersensitivity involves T cells and is typically associated with conditions like contact dermatitis, not bee stings.

Choice D rationale

Type II hypersensitivity is not the correct type of immune reaction for a bee sting. Type II hypersensitivity involves antibody-mediated destruction of cells, which is not the case with bee stings.

Correct Answer is C

Explanation

Choice A rationale

Promoting effective swallowing is important for patients with dysphagia, but it is not the primary goal for a client with a sliding hiatal hernia. The main concern with a sliding hiatal hernia is the prevention of gastroesophageal reflux, which can lead to complications such as esophagitis and Barrett’s esophagus.

Choice B rationale

Maintaining intact oral mucosa is crucial for patients with conditions affecting the mouth, such as oral mucositis or infections. However, it is not the primary goal for a client with a sliding hiatal hernia. The focus should be on preventing reflux and managing symptoms.

Choice C rationale

Preventing esophageal reflux is the primary goal for a client with a sliding hiatal hernia. This condition occurs when the stomach slides up into the chest through the diaphragm, leading to gastroesophageal reflux disease (GERD). Nursing actions should aim to reduce reflux symptoms by advising the client to eat smaller meals, avoid lying down after eating, and elevate the head of the bed.

Choice D rationale

Increasing intestinal peristalsis is important for patients with conditions like constipation or ileus. However, it is not the primary goal for a client with a sliding hiatal hernia. The focus should be on preventing reflux and managing symptoms.

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