A nurse is assessing a patient who has been admitted with shortness of breath. Which of the following should be the nurse's priority intervention after hearing wheezing upon auscultation of the patient's lungs?
Apply supplemental oxygen via nasal cannula.
Elevate the head of the bed to a Fowler's position.
Administer a bronchodilator as prescribed.
Encourage the patient to take deep breaths and cough.
The Correct Answer is C
Rationale:
A. Supplemental oxygen may improve oxygenation, but it does not relieve wheezing, which is caused by airway constriction. Oxygen alone does not treat the underlying problem.
B. Elevating the head of the bed can help ease breathing but is a supportive measure, not the priority for acute airway obstruction.
C. Administering a bronchodilator is the priority because wheezing indicates bronchospasm and narrowed airways. A bronchodilator (such as albuterol) directly relaxes bronchial smooth muscle, improves airflow, and relieves wheezing.
D. Deep breathing and coughing may help mobilize secretions but will not be effective until the airways are opened with a bronchodilator.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Wheezing is associated with airway obstruction (e.g., asthma or COPD), not pleural effusion.
B. Dullness to percussion is a classic finding in pleural effusion because fluid in the pleural space dampens the sound produced during percussion.
C. Increased tactile fremitus occurs with consolidation (e.g., pneumonia), whereas pleural effusion usually decreases fremitus due to fluid separating the lung tissue from the chest wall.
D. Hyperresonance is characteristic of conditions with excess air in the lungs, such as pneumothorax or emphysema, not pleural effusion.
Correct Answer is B
Explanation
Rationale:
A. Respiratory alkalosis occurs with hyperventilation (e.g., anxiety, early asthma attack), not with COPD.
B. Respiratory acidosis is common in COPD due to hypoventilation, carbon dioxide retention, and impaired gas exchange.
C. Metabolic alkalosis usually results from vomiting, gastric suction, or excessive antacid use, not COPD.
D. Metabolic acidosis occurs in conditions like diabetic ketoacidosis or renal failure, not primarily with COPD.
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