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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

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.

Correct Answer is D

Explanation

Choice A rationale

Counting the apical and radial pulses simultaneously is important for assessing pulse deficits, but it is not the most critical assessment for a client receiving hydromorphone.

Choice B rationale

Measuring the client’s capillary glucose level is important for clients with diabetes, but it is not directly related to the administration of hydromorphone.

Choice C rationale

Observing for edema around the ankles is important for assessing fluid retention, but it is not the most critical assessment for a client receiving hydromorphone.

Choice D rationale

Auscultating the client’s bowel sounds is crucial because hydromorphone is a potent opioid analgesic that can slow peristalsis and frequently causes constipation. Monitoring bowel sounds helps prevent complications such as bowel obstruction. .

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