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 D
Explanation
Choice A rationale
Determining the neurological baseline prior to the fall is important but not the immediate priority. The client’s current confusion and projectile vomiting suggest a potential acute condition that needs immediate assessment.
Choice B rationale
Determining the client’s last dose of corticosteroids is relevant for managing multiple sclerosis but does not address the immediate concern of confusion and vomiting.
Choice C rationale
Administering a PRN IV antiemetic as prescribed can help manage vomiting but does not address the underlying cause of the symptoms.
Choice D rationale
Completing a head-to-toe neurological assessment is the priority intervention. The client’s confusion and projectile vomiting could indicate increased intracranial pressure or another acute neurological condition that requires immediate attention.
Correct Answer is A
Explanation
Choice A rationale
Respiratory acidosis is characterized by elevated levels of carbon dioxide (CO2) in the blood due to impaired ventilation. This accumulation of CO2 leads to a decrease in blood pH, making it more acidic.
Choice B rationale
Hyperventilation leads to a rapid elimination of CO2, which would result in respiratory alkalosis, not acidosis. Therefore, this choice does not support the pathophysiological process of respiratory acidosis.
Choice C rationale
Blood oxygen levels stimulating the respiratory rate is a compensatory mechanism for hypoxemia but does not directly cause respiratory acidosis. This process is more related to respiratory alkalosis.
Choice D rationale
The kidneys do play a role in acid-base balance, but they primarily eliminate acids other than CO2. They do not significantly convert CO2 for elimination, making this choice incorrect.