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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
A computerized tomography (CT) scan of the chest is not typically required for routine pneumonia cases unless there are complications or the pneumonia is not responding to standard treatment. CT scans provide more detailed images but are usually reserved for more complex cases.
Choice B rationale:
Albuterol treatments by nebulizer every 4 to 6 hours are appropriate for managing wheezing and bronchospasm associated with pneumonia, especially in a patient with a history of COPD. Albuterol helps open the airways, making it easier for the patient to breathe.
Choice C rationale:
A chest x-ray is a standard diagnostic tool for pneumonia. It helps assess the extent of lung involvement and monitor the progression or resolution of the infection. Repeating the chest x-ray can help evaluate the effectiveness of the treatment.
Choice D rationale:
Increasing oral fluids is essential for patients with pneumonia to help thin mucus, making it easier to expectorate. Adequate hydration also supports overall health and recovery.
Choice E rationale:
Obtaining an arterial blood gas (ABG) is important for assessing the patient’s oxygenation and acid-base status. This information is crucial for managing respiratory distress and ensuring adequate oxygen delivery.
Correct Answer is A
Explanation
Choice A rationale
Hematemesis, or vomiting blood, is a critical sign of bleeding esophageal varices, which can be life-threatening. Clients with chronic cirrhosis and esophageal varices are at high risk for variceal bleeding due to increased portal hypertension. Monitoring for hematemesis is essential to provide timely intervention and prevent complications.
Choice B rationale
Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Choice C rationale
Clay-colored stool indicates a lack of bile in the stool, which can occur in liver disease. However, it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Choice D rationale
Brown, foamy urine can be a sign of liver dysfunction, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.