A client has an oxygen saturation of 88% on room air. Which action should the nurse take first?

Correct Answer: A

Rationale: The correct answer is A: Initiate oxygen therapy at 2 liters per minute via nasal cannula. Oxygen saturation of 88% indicates hypoxemia and requires immediate intervention. Providing supplemental oxygen via nasal cannula will help improve oxygenation. Placing the client in high-Fowler's position may help with ventilation but addressing hypoxemia is the priority. Notifying the healthcare provider is important but immediate intervention is necessary. Documenting the finding is important but should not delay providing oxygen therapy.

Correct Answer: A

Rationale: The correct answer is A: Decreased breath sounds on the affected side. In a pleural effusion, fluid accumulates in the pleural space, leading to decreased air entry and diminished breath sounds on auscultation. This occurs because the fluid dampens the transmission of sound through the lungs. B: Hyperresonance on percussion of the affected side is not expected in pleural effusion, as it is typically associated with conditions like pneumothorax. C: Increased tactile fremitus on the affected side is not a typical finding in pleural effusion. Tactile fremitus may be decreased due to the presence of fluid. D: Tracheal deviation toward the affected side is more commonly seen in conditions like tension pneumothorax, not pleural effusion.

Correct Answer: B

Rationale: The correct answer is B because pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips, which helps improve lung function and relaxes the client. Choice A is incorrect because breathing in quickly through the mouth is not part of pursed-lip breathing technique. Choice C is incorrect as holding breath before exhaling is not recommended in pursed-lip breathing. Choice D is partially correct but lacks the emphasis on inhaling slowly through the nose. Therefore, the most effective statement indicating correct teaching is choice B.

Correct Answer: A

Rationale: The correct answer is A: Albuterol (Proventil). Albuterol is a short-acting beta agonist bronchodilator that provides quick relief during an asthma exacerbation by relaxing the smooth muscles in the airways. This helps to rapidly open up the airways and improve breathing. Administering albuterol first is crucial in managing acute asthma symptoms. Summary of other choices: B: Ipratropium (Atrovent) is an anticholinergic bronchodilator that is often used in combination with albuterol for asthma exacerbations, but albuterol is preferred for initial rapid relief. C: Salmeterol (Serevent) is a long-acting beta agonist used for maintenance treatment of asthma, not for acute exacerbations. D: Fluticasone (Flovent) is an inhaled corticosteroid used for long-term control of asthma symptoms and prevention of exacerbations

Correct Answer: C

Rationale: The correct answer is C. Administer oxygen to maintain saturations above 94%. In asthma exacerbation, maintaining oxygen saturation is crucial to prevent hypoxia. Oxygen therapy helps improve oxygen delivery to tissues and organs. Administering salmeterol (choice A) may help with long-term management but is not an immediate priority. Tracheal deviation assessment (choice B) is not relevant to asthma exacerbation. Performing peak expiratory flow measurements (choice D) may be helpful for monitoring asthma severity but is not the priority in this acute situation.