A client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with a positive airway pressure (CPAP). The clients vital signs are an oral temperature 98.8 °F (37.1 °C) a respiratory rate of 46 breaths/minute, and a blood pressure of 176/92 mm Hg. While completing the pulmonary assessment, the client's oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurse implement?
Increase the oxygen delivery by 10%.
Administer PRN nebulizer treatment.
Complete neurological assessment.
Prepare for rapid sequence intubation.
The Correct Answer is D
A. Increase the oxygen delivery by 10%: While hypoxemia is present, simply increasing oxygen may be insufficient for a client who is difficult to arouse and in severe respiratory distress. Immediate advanced airway intervention is a higher priority.
B. Administer PRN nebulizer treatment: Bronchodilators can improve airway obstruction but will not rapidly correct profound hypoxemia or altered mental status in a critically decompensating client. This intervention alone is not adequate.
C. Complete neurological assessment: Assessing neurological status is important, but the client’s low oxygen saturation and decreased responsiveness indicate a life-threatening situation that requires immediate intervention before completing a full assessment.
D. Prepare for rapid sequence intubation: The client exhibits severe hypoxemia, high respiratory rate, and decreased level of consciousness—signs of impending respiratory failure. Rapid sequence intubation ensures airway protection and adequate ventilation, which is the priority action to prevent respiratory arrest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Gravida-4, Para-3: Gravida refers to the total number of pregnancies, and this client has been pregnant four times (twins, son, fetal loss, and current pregnancy). As there are 2 children from the twins and 1 child aged 4 the parity is 4. The fetal loss at 24 weeks is not considered viable gestational age.
B. Gravida-5, Para-3: This option incorrectly counts one extra pregnancy. The client has had four total pregnancies (not five), and only two resulted in live births beyond 20 weeks. The fetal loss at 24 weeks does not add to the parity count since the baby was not viable.
C. Gravida-4, Para-4: Gravida 4 accounts for all pregnancies, however since the fetal loss is included in the count, the parity is incorrectly stated as 4
D. Gravida-5, Para-2: This option counts the twin pregnancy as two different pregnancies which is incorrect. Parity of 2 does not account for the twins.
Correct Answer is ["0.5"]
Explanation
Prescribed dose = 12.5 mg
Available dose = 25 mg per tablet
Calculate the number of tablets to administer.
Tablets = (Prescribed dose (mg) / Available dose (mg))
= (12.5 mg / 25 mg)
= 0.5 tablet.
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