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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

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.

Correct Answer is C

Explanation

Choice A rationale

Anxiety and grieving are important issues but are not the priority when the client is at risk for aspiration.

Choice B rationale

Chronic pain is significant, but the immediate risk of aspiration due to dysphagia takes precedence.

Choice C rationale

Risk for aspiration related to difficulty swallowing is the priority nursing problem. Aspiration can lead to serious complications such as pneumonia.

Choice D rationale

Imbalanced nutrition is important but is secondary to the immediate risk of aspiration.

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