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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 A

Explanation

Choice A rationale

Asking the client to describe the pain is the best approach to assess the quality of pain. This allows the nurse to gather detailed information about the pain’s characteristics.

Choice B rationale

Identifying effective pain relief measures is important but does not directly assess the quality of pain.

Choice C rationale

Observing body language and movement can provide clues about pain but is not as effective as directly asking the client to describe the pain.

Choice D rationale

Providing a numeric pain scale helps quantify the pain but does not provide detailed information about the pain’s quality.

Correct Answer is A

Explanation

Choice A rationale

Reported history of alcoholism is the most important assessment finding to address before administering terbinafine HCL. Terbinafine is metabolized by the liver, and clients with a history of alcoholism may have impaired liver function, increasing the risk of hepatotoxicity. Monitoring liver function and assessing for signs of liver damage are crucial before starting treatment.

Choice B rationale

Toenails appear thick and yellow is a common symptom of fungal toenail infection, but it is not the most critical assessment finding to address before administering terbinafine HCL. The focus should be on assessing liver function.

Choice C rationale

Employed as a construction worker is not the most critical assessment finding to address before administering terbinafine HCL. While occupational exposure to fungi may be relevant, the primary concern is liver function.

Choice D rationale

White blood cell count of 8,500/mm³ (8.5 x 10⁹/L) is within the normal range and is not the most critical assessment finding to address before administering terbinafine HCL. The primary concern is liver function.

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