A nurse is caring for a client receiving supplemental oxygen. The nurse notes that the client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

Correct Answer: B

Rationale: The correct answer is B: Assess the client for signs of respiratory distress. This is the first action the nurse should take because an oxygen saturation of 88% indicates hypoxemia, which can lead to respiratory distress. By assessing the client, the nurse can determine if the client is in immediate need of intervention. Increasing oxygen flow rate (A) may be necessary, but assessing the client's condition comes first. Notifying the provider (C) can be done after assessing the client's immediate needs. Administering a bronchodilator (D) may be indicated if respiratory distress is due to bronchoconstriction, but assessing the client's overall condition is the priority.

Correct Answer: D

Rationale: The correct answer is D: Oxygen saturation of 88%. This finding is most concerning because it indicates hypoxemia, which can lead to serious complications in a client with chronic bronchitis. Hypoxemia can result in tissue damage and impaired organ function. A low oxygen saturation level requires immediate intervention to prevent further deterioration. Choice A (Productive cough with thick sputum) is a common symptom of chronic bronchitis and may indicate an exacerbation, but it is not as immediately concerning as hypoxemia. Choice B (Clubbing of fingers) is a late sign of chronic hypoxemia and may be present in clients with chronic bronchitis, but it is not as urgent as a low oxygen saturation level. Choice C (Peripheral cyanosis) is also a sign of hypoxemia, but oxygen saturation level provides a more accurate assessment of the client's oxygenation status.

Correct Answer: A

Rationale: The correct answer is A: Administering prescribed analgesics. The priority intervention is to manage the client's pain to promote comfort and encourage deep breathing and coughing. This helps prevent complications such as atelectasis. Positioning for comfort is important but not the priority when the client is experiencing pleuritic chest pain. Assessing for pleural effusion is relevant but not the immediate priority over addressing the client's pain.

Correct Answer: A

Rationale: The correct answer is A: Use the meter before taking bronchodilators. This is because measuring peak flow before using bronchodilators provides a baseline measurement of the client's lung function. Taking bronchodilators could artificially improve the results, making it harder to assess the true severity of the asthma. Explanation for why other choices are incorrect: B: Taking a deep breath and exhaling slowly is not necessary for using a peak flow meter. C: Performing the test while lying down can affect the accuracy of the results as the body position can impact lung function. D: Repeating the test and recording the result may not be necessary unless specifically instructed by the healthcare provider.

Correct Answer: C

Rationale: The correct answer is C: Airborne precautions. Tuberculosis is an airborne disease spread through respiratory droplets. Airborne precautions include wearing an N95 mask, isolating the patient in a negative pressure room, and ensuring proper ventilation. This type of precaution is necessary to prevent the transmission of TB to others. Droplet precautions (choice A) are used for diseases transmitted through larger respiratory droplets. Contact precautions (choice B) are for diseases spread through direct contact with the patient or contaminated surfaces. Standard precautions (choice D) are used for all patients to prevent the spread of infection, but they are not sufficient for TB due to its airborne nature.