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?
Have the client cough and expectorate secretions.
Instruct the client to use a pursed-lip breathing technique.
Increase the oxygen flow to 3 L/min.
Evaluate the client's respiratory status.
The Correct Answer is D
Choice A rationale:
Having the client cough and expectorate secretions is a reasonable intervention for managing respiratory distress, but it is not the top priority. The nurse should first assess the client's overall respiratory status to determine the severity of the problem.
Choice B rationale:
Instructing the client to use a pursed-lip breathing technique is a helpful strategy to improve breathing in some cases. However, it should not be the top priority when a client is experiencing difficulty breathing. Assessment should come first.
Choice C rationale:
Increasing the oxygen flow to 3 L/min without a proper assessment is not advisable. It's essential to evaluate the client's respiratory status before making any adjustments to the oxygen therapy.
Choice D rationale:
"Evaluate the client's respiratory status" is the correct response. When a client with COPD and oxygen therapy reports difficulty breathing, the nurse's priority is to assess the client's respiratory status. This assessment will help determine the cause of the breathing difficulty and guide appropriate interventions. The nurse should also check the oxygen saturation levels, respiratory rate, and auscultate lung sounds to assess the severity of the issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The client's arterial blood gas (ABG) results indicate a low pH (acidemia) and high PaCO2, which is characteristic of respiratory acidosis. Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) from the body, leading to an accumulation of CO2 and a decrease in pH. In this case, the high PaCO2 (50 mm Hg) indicates that the client is retaining carbon dioxide, likely due to impaired ventilation. The normal pH range is 7.35 to 7.45, and the normal PaCO2 range is 35 to 45 mm Hg. These ABG values reflect an acid-base imbalance in the respiratory system, specifically, respiratory acidosis.
Choice B rationale:
Metabolic alkalosis is characterized by an elevated pH and an increase in bicarbonate (HCO3) levels. This is not the condition described in the client's ABG results, as the pH is low (acidemic) and HCO3 levels are within the normal range (24 mEq/L).
Choice C rationale:
Metabolic acidosis is characterized by a low pH and a decreased HCO3 level. The client's ABG results do not align with metabolic acidosis since the pH is low (acidemic) and the HCO3 level is within the normal range (24 mEq/L).
Choice D rationale:
Respiratory alkalosis is characterized by a high pH and low PaCO2. The client's ABG results do not match this condition as the pH is low (acidemic) and the PaCO2 is high (50 mm Hg), indicating respiratory acidosis. Therefore, choice A, respiratory acidosis, is the correct interpretation of the ABG results.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should identify that an effective outcome of IV fluid replacement in a client with dehydration is an increase in urine output. Urine output of 200 mL in 4 hours indicates that the kidneys are responding to the IV fluid replacement, and the client is likely rehydrating. This suggests that the renal perfusion has improved, and the client's body is eliminating waste products properly.
Choice B rationale:
A heart rate of 104 beats per minute is not necessarily indicative of the effectiveness of IV fluid replacement. Heart rate may vary for various reasons, and it is not a specific parameter for assessing the response to hydration. Other factors, such as blood pressure, should be considered to evaluate cardiovascular status.
Choice C rationale:
Peripheral pulses of +1 are not a direct indicator of the effectiveness of IV fluid replacement. While improved hydration may lead to better peripheral perfusion, this assessment is somewhat subjective and may not accurately reflect the overall effectiveness of the treatment.
Choice D rationale:
A urine specific gravity of 1.04 is not indicative of the effectiveness of IV fluid replacement. A specific gravity of 1.004 is within the normal range (normal range: 1.005-1.030) and does not necessarily indicate hydration status. It is essential to focus on urine output and other objective parameters to assess the effectiveness of hydration therapy. .
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