The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which assessment should the nurse prioritize?

Monitor oxygen saturation

Check skin color

Assess for chest pain

Measure blood pressure

Answer and Explanation

The Correct Answer is A

Choice A reason: Monitoring oxygen saturation is critical in COPD, as oxygen therapy aims to maintain saturation (88–92%) to prevent hypoxia. Pulse oximetry ensures adequate oxygenation, guiding therapy adjustments, making it the priority assessment to prevent respiratory failure and optimize lung function.

Choice B reason: Checking skin color assesses cyanosis but is less precise than oxygen saturation. Pulse oximetry provides objective data on oxygenation in COPD, guiding oxygen therapy, making it the priority over subjective visual assessments, which are secondary to quantitative measures.

Choice C reason: Assessing chest pain is relevant for cardiac issues but not the primary concern in COPD oxygen therapy. Oxygen saturation directly evaluates therapy effectiveness, preventing hypoxia, making it the priority assessment to ensure respiratory stability in chronic lung disease.

Choice D reason: Measuring blood pressure monitors cardiovascular status but is secondary to oxygenation in COPD. Oxygen saturation is critical, as hypoxia exacerbates respiratory distress, requiring immediate assessment to adjust oxygen therapy, making it the priority over hemodynamic evaluations.

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Correct Answer is D

Explanation

Choice A reason: Imbalanced nutrition due to anorexia and dysphagia is significant in esophageal cancer, as it risks weight loss and weakness. However, pain at 8/10 is an acute, distressing symptom requiring immediate relief to improve quality of life, making it the priority over nutritional deficits.

Choice B reason: Risk for aspiration from dysphagia is a concern in esophageal cancer, as tumor obstruction can cause swallowing issues. While serious, aspiration is a potential risk, whereas severe pain is an immediate, actual problem, making pain management the priority to alleviate current suffering.

Choice C reason: Anxiety and grieving are valid in esophageal cancer due to its prognosis, but a pain level of 8/10 is an urgent physiological need. Addressing pain first improves the client’s ability to cope with psychological distress, prioritizing physical comfort over emotional concerns.

Choice D reason: Chronic pain from tumor-related tissue destruction, rated 8/10, is the priority, as severe pain causes significant distress and impairs function. Effective pain management enhances comfort, facilitates other interventions, and addresses the client’s immediate suffering, making it the most urgent nursing problem.

A. Suggest that the client also plan to eat frequent small meals to reduce discomfort B. Remind the client to switch to decaffeinated coffee and tea C. Review with the client the need to avoid foods rich in milk and cream D. Reinforce the teaching by asking the client to make a list of snack foods high in dairy content

Correct Answer is A

Explanation

Choice A reason: Frequent small meals reduce gastroesophageal reflux by minimizing gastric distension, which decreases pressure on the lower esophageal sphincter. This prevents acid reflux into the esophagus, alleviating heartburn and irritation, making it an effective dietary strategy for managing GERD symptoms.

Choice B reason: Switching to decaffeinated coffee and tea may reduce reflux triggers, as caffeine relaxes the lower esophageal sphincter. However, small meals are more effective, as they directly reduce gastric volume and sphincter pressure, providing broader symptom relief than caffeine avoidance alone.

Choice C reason: Avoiding milk and cream is relevant for some GERD patients, as high-fat foods delay gastric emptying, increasing reflux. However, frequent small meals address the root cause of reflux by reducing gastric pressure, making this a more universally effective strategy than specific food avoidance.

Choice D reason: Listing high-dairy snack foods reinforces avoidance but is less direct than recommending small meals. Dairy may trigger reflux in some, but frequent small meals broadly reduce gastric distension and sphincter pressure, offering a more immediate and effective GERD management strategy.

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The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which assessment should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

Correct Answer is D

Explanation

The nurse is teaching a client with gastroesophageal reflux disease about dietary modifications. Which instruction should the nurse include?

Correct Answer is A

Explanation

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