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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

Decreasing speaking speed may help with clarity, but it does not address the issue of hearing loss.

Choice B rationale

Over-enunciating word syllables can help the client understand speech better, especially if they have hearing difficulties. This technique makes it easier for the client to read lips and understand spoken words.

Choice C rationale

Raising voice volume to a shout can be uncomfortable and may not improve understanding. It can also be perceived as rude or aggressive.

Choice D rationale

Exaggerating nonverbal expressions may help with communication, but it is not as effective as over-enunciating word syllables for clients with hearing difficulties.

Correct Answer is D

Explanation

Choice A rationale

Flatulence is not a specific indicator of a serious complication related to a gallstone lodged in the common bile duct.

Choice B rationale

Amber urine is normal and does not indicate a serious complication.

Choice C rationale

Belching is not a specific indicator of a serious complication related to a gallstone lodged in the common bile duct.

Choice D rationale

Yellow sclera indicates jaundice, which is a sign of bile duct obstruction and requires immediate medical attention.

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