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.

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Correct Answer is A

Explanation

Choice A rationale:

Metabolic alkalosis Metabolic alkalosis is characterized by an elevated pH (above the normal range of 7.35-7.45) and an increased bicarbonate (HCO3) level (above the normal range of 22-28 mEq/L). In this case, the client's pH of 7.6 and HCO3 level of 32 mEq/L indicate a primary metabolic alkalosis. It can be caused by excessive bicarbonate intake, loss of acid (as in vomiting or excessive diuretic use), or other factors that result in an excess of bicarbonate in the body. The PaCO2 level is within the normal range (35-45 mm Hg), which is consistent with compensatory hypoventilation seen in metabolic alkalosis.

Choice B rationale:

Metabolic acidosis Metabolic acidosis is characterized by a decreased pH and bicarbonate level. The client's ABG results do not align with metabolic acidosis. In this case, the pH is elevated, and the bicarbonate level is above the normal range.

Choice C rationale:

Respiratory alkalosis Respiratory alkalosis is characterized by an elevated pH and decreased PaCO2. The client's ABG results show a normal PaCO2 of 40 mm Hg, which does not align with respiratory alkalosis. In respiratory alkalosis, you would typically see a lower PaCO2.

Choice D rationale:

Respiratory acidosis Respiratory acidosis is characterized by a decreased pH and elevated PaCO2. The client's ABG results do not align with respiratory acidosis. In this case, the PaCO2 is within the normal range, and the pH is elevated, which is not indicative of respiratory acidosis.

A. Withhold the digoxin dose for decreased heart rate. B. Administer digoxin 0.25 mg. C. Administer digoxin 0.125 mg. D. Withhold the digoxin dose for elevated BP. .

Correct Answer is A

Explanation

Choice A rationale:

Withholding the digoxin dose for a decreased heart rate is the correct action. Digoxin is a medication used to treat heart failure, but it can lead to bradycardia (slow heart rate) as a side effect. In this scenario, the client's heart rate is already at 54 beats per minute, which is below the normal range. Administering digoxin could further slow the heart rate, potentially leading to dangerous bradycardia or heart block. Withholding the medication is essential to prevent this adverse event.

Choice B rationale:

Administering digoxin 0.25 mg is not the appropriate action in this case. The client's heart rate is already below the normal range, and giving the full dose of digoxin could further depress the heart rate and increase the risk of bradycardia. Withholding the medication is the safer course of action.

Choice C rationale:

Administering digoxin 0.125 mg is not recommended because the client's heart rate is already below the normal range. While a reduced dose may be considered in some situations, it's essential to withhold the medication and consult with the healthcare provider in this specific case, as the client's heart rate is significantly low.

Choice D rationale:

Withholding the digoxin dose for elevated BP is not the appropriate action. Digoxin is primarily used to treat heart failure by increasing the force of cardiac contractions. Elevated blood pressure is not an indication to withhold digoxin. The focus should be on addressing the low heart rate in this scenario. .

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGs are:. A. pH: 7.6. B. PaCO2: 40 mm Hg. C. HCO3: 32 mEq/L. Which of the following acid-base conditions should the nurse identify the client is experiencing?

Correct Answer is A

Explanation

A nurse is caring for a client who has a prescription for digoxin 0.25 mg P.O. daily for heart failure.The client's current vital signs are: BP 144/96, heart rate 54/min, respirations 18/min, and temperature 37°C (98.6°F). Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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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?