A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.
The client tells the nurse she has been having difficulty breathing.
Which of the following actions is the nurse's priority at this time?

Choice A rationale:

Check the client's respiratory rate and lung sounds When an IV bag is unexpectedly empty, it is important to assess the client for potential complications, especially if the client was receiving fluid therapy. Checking the respiratory rate and lung sounds is essential to ensure there are no signs of respiratory distress, such as crackles or wheezing, which could indicate fluid overload or a pulmonary issue.

Choice B rationale:

Request NPO status for the client Requesting nothing by mouth (NPO) status is not the immediate action required when an IV bag is empty. The priority is to assess the client's condition and address any potential issues first.

Choice C rationale:

Elevate the head of the bed to high Fowler's Elevating the head of the bed to high Fowler's is a measure to assist with preventing aspiration during oral intake. It is not the primary action required in this situation, where assessing the client's respiratory and fluid status is more important.

Choice D rationale:

Measure the client's temperature Measuring the client's temperature is not the immediate priority in this scenario. Assessing the client's respiratory and fluid status is more critical to identify any potential issues associated with the empty IV bag. .

Choice A rationale:

"I can plan to eat rice instead of baked potatoes.”. This choice demonstrates an understanding of dietary sources of potassium. Baked potatoes are a good source of potassium, and the client's willingness to substitute rice for baked potatoes indicates that they are aware of alternative potassium-rich foods. Potassium is essential for various bodily functions, including maintaining proper heart and muscle function. The client's willingness to make a dietary adjustment is a positive sign.

Choice B rationale:

"Adding pecans will be a change I can readily make.”. While pecans are a good source of potassium, this choice does not directly address the client's ability to substitute a potassium-rich food for one they might need to avoid. It focuses on a new addition to their diet rather than a substitution, making it a less relevant response to the teaching.

Choice C rationale:

"I will eat cantaloupe for my morning snack.”. Cantaloupe is indeed a good source of potassium, but this choice does not indicate an understanding of how to substitute potassium-rich foods in their diet. It only mentions adding cantaloupe as a snack without addressing the potential need for replacing other foods high in potassium. Therefore, it does not fully demonstrate comprehension of the teaching.

Choice D rationale:

"I will miss eating yogurt every day for breakfast.”. This choice expresses a sentiment but does not show an understanding of the teaching regarding dietary sources of potassium. It merely states that the client will miss yogurt without providing any insight into their ability to make appropriate dietary choices to maintain adequate potassium intake.