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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

The correct answer is choiceA. Heart rate 50/min.

Choice A rationale:

Atenolol is a beta-blocker that can significantly lower heart rate.A heart rate of 50/min is considered bradycardia (slow heart rate), and administering atenolol could further decrease the heart rate to a dangerously low level. Therefore, the nurse should withhold the medication in this case.

Choice B rationale:

A respiratory rate of 18/min is within the normal range (12-20 breaths per minute) and does not contraindicate the use of atenolol. Therefore, this finding would not require withholding the medication.

Choice C rationale:

An oxygen saturation of 95% is within the normal range (typically 95-100%) and does not contraindicate the use of atenolol. Thus, this finding would not necessitate withholding the medication.

Choice D rationale:

While a blood pressure of 160/94 mm Hg indicates hypertension, atenolol is often prescribed to manage high blood pressure. Therefore, this finding would not require withholding the medication.

A. Collecting data from a client who reports unilateral calf pain when ambulating. B. Taking a telephone prescription for a client who is to be transferred from PACU. C. Reassuring the partner of a client who sustained a closed head injury. D. Reinforcing a client's dressing on an above-the-knee amputation surgical site.

Correct Answer is A

Explanation

Choice A rationale:

The nurse should prioritize collecting data from a client who reports unilateral calf pain when ambulating. This symptom could indicate the presence of a deep vein thrombosis (DVT), a potentially life-threatening condition. DVT occurs when a blood clot forms in a deep vein, often in the lower extremities. If left untreated, the clot can dislodge and travel to the lungs, causing a pulmonary embolism. Immediate assessment is crucial to rule out DVT and provide appropriate interventions. The nurse should assess the client's calf for swelling, redness, warmth, and tenderness and may also order diagnostic tests like a duplex ultrasound.

Choice B rationale:

Taking a telephone prescription for a client being transferred from the PACU is important but not the top priority in this situation. While timely transfer and adequate post-operative care are essential, addressing a client with unilateral calf pain and the potential for a DVT takes precedence due to the risk of a life-threatening complication.

Choice C rationale:

Reassuring the partner of a client who sustained a closed head injury is a compassionate action but should not be the first priority. The partner's emotional support can be provided once the immediate medical concerns have been addressed.

Choice D rationale:

Reinforcing a client's dressing on an above-the-knee amputation surgical site is important for the client's post-operative care, but it is not the highest priority when compared to the possibility of a DVT. The nurse should address the client's calf pain first and then attend to the dressing reinforcement.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client prior to administering atenolol. For which of the following findings should the nurse withhold the medication?

Correct Answer is A

Explanation

A nurse is planning care for a group of clients on a medical-surgical unit.Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?

A nurse is reinforcing teaching about self-management strategies with a client who has emphysema. Which of the following client statements indicates that the client understands the instructions?

A nurse is reinforcing teaching with a client who is scheduled for an exercise ECG stress test.Which of the following comments should indicate to the nurse that the client requires further instructions?

A nurse is reinforcing discharge teaching on actions that improve gas exchange to a client diagnosed with emphysema.Which of the following instructions should be included in the teaching?

A nurse is assisting with planning interventions for an influenza outbreak in a long-term care facility.Which of the following interventions should the nurse include in the plan?

A nurse is reviewing the laboratory results of a client who is taking a loop diuretic and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect related to the client's hypokalemia?

The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

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?