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
Reviewing with the client the need to avoid foods rich in milk and cream is crucial. Dairy products can increase gastric acid secretion, which can exacerbate duodenal ulcers.
Choice B rationale
Suggesting frequent small meals can help reduce discomfort but does not address the issue of dairy products exacerbating the ulcer.
Choice C rationale
Switching to decaffeinated coffee and tea is beneficial but not as critical as avoiding dairy products.
Choice D rationale
Reinforcing teaching by asking the client to list dairy foods does not address the need to avoid these foods.
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.