A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety?

Choice A reason: NPO status rests the pancreas, reducing enzyme secretion in acute pancreatitis. This aligns with treatment protocols, making it a correct intervention the nurse would expect to be prescribed for the client to manage pancreatic inflammation effectively.

Choice B reason: Coughing and deep breathing prevent respiratory complications like atelectasis in pancreatitis patients, who are often immobile. This aligns with standard care, making it a correct intervention the nurse would anticipate in the client’s treatment plan.

Choice C reason: Small, frequent high-calorie feedings are contraindicated in acute pancreatitis, as they stimulate the pancreas. NPO is correct, making this incorrect, as it’s inappropriate for the nurse’s expected interventions in managing acute pancreatitis.

Choice D reason: Supine and flat positioning may increase discomfort and aspiration risk in pancreatitis. Semi-Fowler’s is preferred, making this incorrect, as it’s not an expected intervention compared to the nurse’s focus on optimal positioning for the client.

Choice E reason: Hydromorphone IV provides effective pain relief in acute pancreatitis, reducing patient discomfort. This aligns with pain management protocols, making it a correct intervention the nurse would expect to be prescribed for the client’s care.

Choice F reason: IV fluids at 10 mL/hr are insufficient for pancreatitis, which requires aggressive hydration. Higher rates are standard, making this incorrect, as it’s inadequate compared to the nurse’s expected fluid management in acute pancreatitis treatment.

Choice A reason: Hypertension is not typical in anaphylactic shock, which causes vasodilation and hypotension. Hypotension is a key finding, making this incorrect, as it contradicts the expected cardiovascular response in the nurse’s assessment of a client with anaphylactic shock.

Choice B reason: Crackles indicate fluid overload or pneumonia, not anaphylaxis, which causes bronchoconstriction and wheezing. Pruritus is typical, making this incorrect, as it doesn’t align with the respiratory findings the nurse would expect in anaphylactic shock assessment.

Choice C reason: Cutaneous cyanosis reflects poor oxygenation from airway compromise in anaphylactic shock. This aligns with integumentary and respiratory assessment, making it a correct finding the nurse would identify in a client experiencing anaphylactic shock in the ED.

Choice D reason: Pruritus, often with hives, is a hallmark of anaphylactic shock due to histamine release. This aligns with allergic response assessment, making it a correct finding the nurse would expect in a client with anaphylactic shock in the emergency department.

Choice E reason: Cough may occur but is less specific than wheezing, which indicates bronchoconstriction in anaphylaxis. Hypotension is more critical, making this incorrect, as it’s not a primary finding compared to the nurse’s expected signs of anaphylactic shock.

Choice F reason: Wheezing results from bronchoconstriction in anaphylactic shock, reflecting airway narrowing. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.

Choice G reason: Hypotension is a cardinal sign of anaphylactic shock due to vasodilation and fluid shifts. This aligns with cardiovascular assessment, making it a correct finding the nurse would identify in a client with anaphylactic shock in the emergency setting.

Choice H reason: Restlessness indicates hypoxia or anxiety in anaphylactic shock, a common neurological response. This aligns with clinical assessment findings, making it a correct manifestation the nurse would expect in a client experiencing anaphylactic shock in the ED.