A client with chronic obstructive pulmonary disease (COPD) is admitted with acute exacerbation and respiratory distress. Which finding requires immediate intervention by the nurse?

Oxygen saturation of 88% on room air

Respiratory rate of 26 breaths/min

Use of accessory muscles to breathe

Arterial pH of 7.28

Answer and Explanation

The Correct Answer is D

Choice A reason: Oxygen saturation of 88% in COPD is low but may be baseline for severe disease. It warrants oxygen therapy but is not the most urgent finding. Arterial pH of 7.28 indicates acute respiratory acidosis, a life-threatening complication requiring immediate ventilatory support to correct CO2 retention and acid-base imbalance.

Choice B reason: A respiratory rate of 26 breaths/min indicates tachypnea, common in COPD exacerbation, but is not immediately life-threatening. It reflects respiratory effort to compensate for hypoxia. Arterial pH of 7.28 suggests acute acidosis from CO2 retention, requiring urgent intervention like non-invasive ventilation, making tachypnea a lower priority.

Choice C reason: Accessory muscle use indicates increased work of breathing in COPD exacerbation, signaling distress but not immediate danger. It reflects compensatory efforts for airway obstruction. Arterial pH of 7.28 indicates severe acidosis, a life-threatening condition requiring urgent ventilatory support, making muscle use less critical in this scenario.

Choice D reason: Arterial pH of 7.28 in a COPD exacerbation indicates acute respiratory acidosis due to CO2 retention from hypoventilation. This life-threatening imbalance can lead to coma or cardiac arrest if uncorrected. Immediate intervention, such as non-invasive ventilation, is needed to restore pH and CO2 levels, making this the priority finding.

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Correct Answer is B

Explanation

Choice A reason: IV antibiotics are critical in septic shock to treat the underlying infection, but they take hours to act. Hypotension (80/50 mm Hg) and elevated lactate indicate tissue hypoperfusion, requiring immediate restoration of blood pressure. Vasopressors address shock more rapidly, making antibiotics secondary in the acute stabilization phase.

Choice B reason: Septic shock with blood pressure of 80/50 mm Hg and elevated lactate indicates severe hypoperfusion and tissue hypoxia. Vasopressor therapy, like norepinephrine, restores blood pressure, improving organ perfusion. The ABCDE approach prioritizes circulation, making vasopressors the immediate intervention to prevent organ failure and death in this critical condition.

Choice C reason: Obtaining blood cultures identifies the causative organism in septic shock, guiding antibiotic therapy. However, it does not address immediate hypotension and hypoperfusion, indicated by low blood pressure and high lactate. Vasopressors stabilize circulation first, making cultures a secondary step in the acute management of septic shock.

Choice D reason: IV corticosteroids may be used in refractory septic shock to support adrenal function, but they are not the first-line intervention. Hypotension and elevated lactate require immediate vasopressor therapy to restore perfusion. Corticosteroids are adjunctive and slower-acting, making them less critical than vasopressors in the initial stabilization of septic shock.

A. A client with smoke inhalation who has wheezes and altered mental status B. A client with 40% total body surface area (TBSA) burns who is receiving IV fluids at 250 mL/hour C. A client with full thickness leg burns who has a dressing change scheduled D. A client with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

Correct Answer is A

Explanation

Choice A reason: Smoke inhalation with wheezes and altered mental status indicates potential airway compromise and hypoxemia, critical in the ABCDE approach. Wheezing suggests bronchospasm or edema, and altered mental status may reflect cerebral hypoxia or carbon monoxide poisoning, requiring immediate assessment and intervention to secure the airway and restore oxygenation.

Choice B reason: A client with 40% TBSA burns receiving IV fluids at 250 mL/hour is being treated for hypovolemia, a circulation issue in the ABCDE approach. While serious, this client is stable with ongoing treatment. Airway and breathing issues, as in smoke inhalation with altered mental status, take precedence due to rapid lethality.

Choice C reason: Full-thickness leg burns with a scheduled dressing change address infection risk and wound care, which are important but not immediate priorities. The ABCDE approach prioritizes airway and breathing over wound management. Smoke inhalation with neurological changes indicates a more urgent threat to life, requiring assessment before routine procedures.

Choice D reason: Level 8 pain in abdominal burns is significant and requires management, but pain is addressed after airway, breathing, and circulation in the ABCDE approach. Smoke inhalation with wheezes and altered mental status suggests airway compromise and hypoxemia, which are more immediate threats, making pain control a lower priority.

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A client with chronic obstructive pulmonary disease (COPD) is admitted with acute exacerbation and respiratory distress. Which finding requires immediate intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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