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","B","C"]
Explanation
A. Encourage client to retain solution for at least 5 minutes: Retaining the enema allows the solution to soften stool and stimulate peristalsis effectively, promoting bowel evacuation. Short retention reduces effectiveness.
B. Position client in left lateral recumbent position to expose buttocks: The left lateral position (Sims’ position) aligns the rectum and sigmoid colon to facilitate easier insertion of the enema tip and optimal flow of solution.
C. Insert lubricated tip of tubing 3 to 4 inches into the rectum: Proper insertion depth ensures the solution reaches the rectum without causing trauma. Lubrication minimizes discomfort and risk of injury to the rectal mucosa.
D. Clamp enema administration tubing after filling enema bag: Clamping should occur before attaching the bag to prevent uncontrolled flow. Waiting until after filling is unsafe and can result in premature solution release.
E. Chill the enema solution to help reduce the client's fever: Enema solutions should generally be at room or body temperature. Cold solutions may cause cramping, discomfort, or reflex contraction of the rectum, and do not reduce systemic fever.
Correct Answer is B
Explanation
A. Bulging fontanel: A bulging fontanel may indicate increased intracranial pressure rather than dehydration. In dehydration, the fontanel is typically sunken rather than bulging.
B. Weak cry without any tears: Absence of tears when crying and a weak cry are classic signs of dehydration in infants. These findings indicate fluid loss and inadequate hydration, which is especially concerning in conditions like pyloric stenosis with frequent vomiting.
C. Visible peristaltic wave: A visible peristaltic wave across the abdomen is characteristic of pyloric stenosis itself but does not indicate dehydration. It reflects gastric contractions trying to move contents past the narrowed pylorus.
D. Palpable mass in the right upper quadrant: The palpable “olive-shaped” mass in the right upper quadrant is a hallmark diagnostic finding for pyloric stenosis but is unrelated to the infant’s hydration status.
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