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1. A nurse is caring for a client who has a history of chronic obstructive
pulmonary disease (COPD) and is experiencing an acute exacerbation.
The nurse notes that the client's oxygen saturation is 88% on room air.
Which of the following actions should the nurse take first?
a) Administer supplemental oxygen via nasal cannula.
b) Encourage the client to use pursed-lip breathing.
c) Obtain a chest x-ray to rule out pneumonia.
d) Administer bronchodilator medication via nebulizer.
*Answer: A. The nurse should follow the ABC (airway, breathing,
circulation) priority-setting framework and address the client's hypoxemia
first by providing supplemental oxygen. This will improve the client's
oxygen delivery and prevent further complications.*
b) Encouraging the client to use pursed-lip breathing is a helpful technique
to promote gas exchange and prevent air trapping, but it is not the first
action the nurse should take.
c) Obtaining a chest x-ray is a diagnostic test that may be ordered to
determine the cause of the client's exacerbation, but it is not the first
action the nurse should take.
d) Administering bronchodilator medication via nebulizer is a
pharmacological intervention that may be prescribed to improve the
client's airway patency and respiratory function, but it is not the first
action the nurse should take.
2. A nurse is reviewing the laboratory results of a client who has end-stage
renal disease (ESRD) and is receiving hemodialysis three times per week.
The nurse notes that the client's serum potassium level is 6.2 mEq/L.
Which of the following manifestations should the nurse monitor for in this
client?
a) Muscle weakness
b) Hypotension
c) Polyuria
d) Hyperreflexia
*Answer: A. The nurse should monitor for muscle weakness in this client,
as hyperkalemia (elevated serum potassium level) can cause impaired
neuromuscular function and cardiac dysrhythmias.*
b) Hypotension is not a manifestation of hyperkalemia, but rather of
hypokalemia (low serum potassium level), which can occur due toÂ
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