A client with chronic obstructive pulmonary disease (COPD) receives oxygen therapy. Which finding requires immediate intervention by the nurse?

Correct Answer: B

Rationale: The correct answer is B: Respiratory rate of 10 breaths per minute. In a client with COPD, a respiratory rate of 10 breaths per minute indicates severe respiratory depression and impending respiratory failure. Immediate intervention is necessary to prevent hypoxia and respiratory arrest. Oxygen saturation of 91% (choice A) is low but not as critical as a low respiratory rate. Shortness of breath (choice C) is expected in COPD but does not indicate immediate danger. Use of accessory muscles (choice D) is a sign of respiratory distress, but a low respiratory rate is more concerning for imminent respiratory failure.

Correct Answer: A

Rationale: The correct answer is A because the ability to ambulate without dyspnea indicates effective oxygen therapy. When a client can move without experiencing difficulty breathing, it suggests that the oxygen therapy is adequately supporting their oxygenation needs. In contrast, options B, C, and D do not directly indicate the effectiveness of oxygen therapy. Option B (respiratory rate of 24 breaths per minute) may be within normal range but does not confirm the therapy's efficacy. Option C (oxygen saturation of 92%) is below the desired range of 95-100%, indicating inadequate oxygenation. Option D (productive cough) is unrelated to the assessment of oxygen therapy effectiveness.

Correct Answer: C

Rationale: Step-by-step rationale for choice C (Administer oxygen to maintain saturations greater than 94%): 1. Oxygen is crucial in managing asthma exacerbations to improve oxygen saturation levels and prevent hypoxemia. 2. Decreased pulse oxygen saturation indicates hypoxemia, which can lead to serious complications. 3. Maintaining saturations greater than 94% ensures adequate oxygenation of tissues and organs. 4. Administering oxygen promptly can help alleviate respiratory distress and improve the client's condition. Summary of why other choices are incorrect: - Choice A (Administer albuterol inhaler): While albuterol is a common medication for asthma, oxygen therapy is the priority in this scenario to address hypoxemia. - Choice B (Assess for tracheal deviation): Tracheal deviation is not typically associated with asthma exacerbations and is not the most urgent action needed in this situation. - Choice D (Perform peak expiratory flow measurements): Peak expiratory flow

Correct Answer: B

Rationale: The correct answer is B: Tracheal deviation. Tracheal deviation indicates a tension pneumothorax, a life-threatening emergency that requires immediate intervention to prevent respiratory compromise. The other choices are incorrect because: A: Production of pink sputum may indicate bleeding but does not require immediate intervention unless severe. C: Drainage greater than 70 mL/hr may indicate a potential issue with the chest tube, but it does not require immediate intervention unless accompanied by other symptoms. D: Sudden onset of shortness of breath is concerning but not as immediately life-threatening as tracheal deviation in this context.

Correct Answer: D

Rationale: The correct answer is D: Eat high-fiber foods to promote gastric emptying. In COPD, patients may experience slow gastric emptying due to decreased lung function. High-fiber foods can help with digestion and prevent constipation. A: Avoid drinking fluids just before and during meals - Incorrect. Hydration is important for COPD patients, but timing of fluid intake is not directly related to nutrition in this context. B: Rest before meals if experiencing dyspnea - Incorrect. While resting before meals can help with dyspnea, it is not directly related to nutrition education. C: Have about six small meals a day - Incorrect. While small frequent meals may be beneficial for some COPD patients, this is not a universal recommendation for all individuals with COPD in terms of nutrition.