A client with a history of COPD has a respiratory rate of 28/min, SpO2 of 88%, and is on 2 L of oxygen via nasal cannula. What is the priority nursing intervention?
Increase oxygen to 4 L/min.
Contact the healthcare provider immediately.
Administer a bronchodilator.
Sit the client in a high Fowler's position.
The Correct Answer is D
A. Increasing oxygen flow without assessment or provider order can be unsafe for clients with COPD, as they may rely on hypoxic drive for respiration; abrupt increases can depress their respiratory drive.
B. Contacting the healthcare provider is important but is not the immediate priority; the nurse must first implement interventions that address airway and ventilation.
C. Administering a bronchodilator may be indicated, but the nurse should first ensure the client’s airway is optimized and oxygenation is supported.
D. Sitting the client in a high Fowler’s position is the priority intervention because it promotes lung expansion, improves ventilation, and enhances oxygenation. Positioning is a non-invasive, immediate action that addresses respiratory distress while other interventions are being prepared.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Guiding the client away from background noise improves the ability to hear and understand spoken instructions, as hearing deficits are often exacerbated by environmental noise. This action supports effective communication and client comprehension.
B. Standing next to the client is less effective; the nurse should face the client directly so that lip movements and facial expressions are visible, which aids understanding.
C. Repeating misunderstood phrases may help, but without addressing environmental factors such as noise, communication may still be impaired.
D. Providing instructions in Braille is appropriate for clients with visual impairments, not hearing deficits.
Correct Answer is ["B","C","E"]
Explanation
A. The SDS does not necessarily contain every chemical in the facility, only those that are hazardous or require safety precautions.
B. The SDS lists steps to take for chemical exposure, including first aid measures, emergency procedures, and decontamination instructions, which is a key component of chemical safety.
C. The SDS contains the facility contact person or department to notify in case of chemical exposure, ensuring proper reporting and management of incidents.
D. The SDS does not typically provide the exact location of chemical exposure kits, though it may reference emergency equipment; location details are found in facility-specific protocols.
E. The SDS contains information about the risks associated with chemical exposure, including health hazards, flammability, reactivity, and potential environmental impact, helping staff take necessary precautions.
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