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?
Attach humidification to oxygen delivery.
Coach through using huff coughing.
Obtain a pulse oximetry reading.
Provide nebulizer breathing treatment.
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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Correct Answer is A
Explanation
Choice A rationale
Corneal abrasion is a contraindication for the use of ophthalmic ketorolac. Ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can delay healing and increase the risk of further damage to the cornea.
Choice B rationale
Chemical burns are not a primary contraindication for ophthalmic ketorolac. However, the treatment of chemical burns typically involves other specific interventions, and the use of ketorolac should be carefully considered.
Choice C rationale
Radiation exposure is not a direct contraindication for the use of ophthalmic ketorolac. The medication is used to reduce inflammation and pain, which may be beneficial in managing symptoms related to radiation exposure.
Choice D rationale
A foreign body in the eye is not a primary contraindication for ophthalmic ketorolac. However, the foreign body should be removed, and the eye should be thoroughly examined before administering any medication.
Correct Answer is B
Explanation
Choice A rationale
Serum blood glucose level is not directly related to the presence of purulent drainage at a wound site. While blood glucose levels can affect wound healing, they do not provide specific information about the presence of infection.
Choice B rationale
Culture for sensitive organisms is the most appropriate laboratory value to note when purulent drainage is observed. This test helps identify the specific bacteria causing the infection and determines the most effective antibiotics for treatment.
Choice C rationale
C-reactive protein (CRP) level is a marker of inflammation and can indicate the presence of an infection, but it does not provide specific information about the bacteria causing the infection.
Choice D rationale
Blood pH level is not directly related to the presence of purulent drainage at a wound site. While blood pH can be affected by severe infections, it is not a specific indicator of wound infection.