A client with emphysema is receiving oxygen therapy at 2 L/min. The client reports increasing shortness of breath. What is the nurse's priority action?

Correct Answer: C

Rationale: In this scenario, the nurse's priority action should be option C: assess the client's respiratory status and oxygen saturation. This is the correct answer because when a client with emphysema on oxygen therapy reports increasing shortness of breath, it is crucial to first assess their current respiratory status and oxygen saturation levels. These assessments provide immediate information about the client's oxygenation status and help the nurse determine the appropriate next steps in care. Option A, increasing the oxygen flow rate to 4 L/min, is not the priority action because changing the oxygen flow without assessing the client's status can be potentially harmful. It is important to gather data before making any adjustments to the oxygen therapy. Option B, notifying the healthcare provider immediately, is also not the priority at this moment. While it is essential to involve the healthcare provider in the client's care, assessing the client's condition should come first to provide timely and appropriate interventions. Option D, positioning the client in high Fowler's position, may help improve ventilation but does not address the immediate need to assess the client's respiratory status and oxygen saturation levels. In an educational context, this question highlights the significance of prioritizing assessments in nursing care. It reinforces the importance of data collection and critical thinking in making clinical decisions. Understanding the rationale behind prioritizing actions based on assessment findings is crucial for safe and effective nursing practice, especially in situations where prompt interventions are necessary to ensure patient safety and well-being.

Correct Answer: B

Rationale: The correct answer is B) Prepare the client for a thoracentesis. In the context of a client with pleural effusion experiencing severe shortness of breath, a thoracentesis is the priority intervention to remove the accumulated fluid from the pleural space, relieving pressure on the lungs and improving oxygenation. This procedure can rapidly improve the client's breathing and oxygen levels, addressing the immediate respiratory distress. Option A) Position the client on the unaffected side may provide some comfort but does not address the underlying cause of the shortness of breath, which is the pleural effusion compromising lung expansion. Option C) Administer prescribed diuretics may be part of the treatment plan for managing pleural effusion in the long term by reducing fluid retention, but it is not the immediate priority in a client experiencing severe respiratory distress. Option D) Encouraging deep breathing exercises is not appropriate when the client is in severe respiratory distress due to pleural effusion. The priority is to relieve the pressure on the lungs through thoracentesis before focusing on breathing exercises. In an educational context, understanding the priority interventions for clients with respiratory conditions like pleural effusion is crucial for nurses to provide timely and effective care, especially in acute situations where respiratory compromise can quickly escalate. This question highlights the importance of critical thinking and prioritization in nursing practice, emphasizing the significance of addressing the root cause of respiratory distress to ensure optimal patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) Rinse your mouth after each use. This teaching point is crucial for a client using a corticosteroid inhaler for COPD to prevent the development of oral thrush, a common side effect of inhaled corticosteroids. Rinsing the mouth helps to remove any medication residue that could lead to fungal overgrowth in the mouth. Option A) Use the inhaler only when symptoms worsen is incorrect because corticosteroid inhalers are typically used on a regular schedule to manage inflammation and prevent symptoms from worsening. Option C) Shake the inhaler only if symptoms persist is incorrect because corticosteroid inhalers need to be shaken before each use to ensure proper dispersion of the medication for effective delivery to the lungs. Option D) Use the inhaler before a bronchodilator is incorrect because bronchodilators are usually used first to help open the airways, followed by corticosteroid inhalers to reduce inflammation. In an educational context, it is essential for nurses to provide clear and accurate instructions on the use of inhalers to promote optimal therapeutic outcomes and prevent adverse effects. Teaching patients about proper inhaler technique and potential side effects empowers them to effectively manage their condition and improve their quality of life.

Correct Answer: A

Rationale: In this scenario, option A, a heart rate of 115 beats per minute, is the most concerning assessment finding. The rationale behind this is that an elevated heart rate can indicate cardiac stress or overstimulation from the bronchodilator, potentially leading to cardiac complications. Option B, an oxygen saturation of 90%, while suboptimal, may be expected in a client receiving a bronchodilator for oxygenation issues. It is concerning but not as immediately critical as an elevated heart rate. Option C, a respiratory rate of 22 breaths per minute, is within normal range and does not immediately indicate a critical issue. Option D, the client reporting mild hand tremors, is a common side effect of bronchodilators and is not as concerning as the potential cardiac implications of an elevated heart rate. Educationally, understanding these assessment findings in the context of administering bronchodilators is crucial for nurses to ensure prompt recognition of potential complications and appropriate intervention to optimize patient outcomes. Nursing students preparing for the NCLEX need to grasp the prioritization of assessments to provide safe and effective care to clients receiving respiratory treatments.

Correct Answer: A

Rationale: The correct answer is A) Administer 100% oxygen via a non-rebreather mask. The top priority in treating carbon monoxide poisoning is to increase the oxygen-carrying capacity of the blood. Carbon monoxide binds to hemoglobin with a much higher affinity than oxygen, leading to tissue hypoxia. By administering 100% oxygen, the nurse helps to displace carbon monoxide from hemoglobin and increase the oxygen saturation in the blood, which is crucial in treating carbon monoxide poisoning. Option B) Monitor for signs of respiratory acidosis is incorrect because while carbon monoxide poisoning can lead to tissue hypoxia, it does not primarily cause respiratory acidosis. Option C) Obtain an arterial blood gas sample is not the priority as initiating treatment to address the hypoxia is more critical before confirming the diagnosis. Option D) Placing the client in a high Fowler's position would not directly address the underlying issue of carbon monoxide poisoning and is not the most urgent intervention in this situation. In an educational context, understanding the priority actions in managing carbon monoxide poisoning is vital for nurses to provide timely and effective care. This scenario highlights the importance of recognizing the pathophysiology of carbon monoxide poisoning and the immediate interventions required to improve oxygenation and patient outcomes.