A client with a history of chronic heart failure is experiencing severe shortness of breath and has pink, frothy sputum. Which action should the nurse take first?

Correct Answer: B

Rationale: The correct action for the nurse to take first is to place the client in a high Fowler's position (Choice B). This position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and improving ventilation. With severe shortness of breath and pink, frothy sputum, the priority is to optimize respiratory function. Administering morphine sulfate (Choice A) may be indicated later for pain and anxiety but is not the immediate priority. Initiating continuous ECG monitoring (Choice C) is important but not as urgent as addressing the respiratory distress. Preparing the client for intubation (Choice D) should be considered if respiratory distress worsens, but initial interventions should focus on improving oxygenation through positioning.

Correct Answer: A

Rationale: The correct answer is A: Increased anteroposterior chest diameter. In COPD, the chronic airway obstruction leads to air trapping, causing the chest to become hyperinflated. This results in an increase in the anteroposterior chest diameter, often referred to as "barrel chest." Explanation for why other choices are incorrect: B: Decreased respiratory rate is not typically seen in COPD; patients often exhibit an increased respiratory rate due to difficulty breathing. C: Dull percussion sounds over the lungs are associated with conditions like pneumonia or pleural effusion, not COPD. D: Hyperresonance on chest percussion is typically found in conditions like emphysema, a type of COPD, but it is not specific to COPD as a whole.

Correct Answer: B

Rationale: The correct answer is B: Notify the healthcare provider. A prolonged aPTT of 90 seconds indicates the client is at risk for bleeding due to excessive anticoagulation from heparin therapy. The nurse should notify the healthcare provider immediately to adjust the dosage or consider discontinuing heparin to prevent bleeding complications. Increasing the heparin infusion rate (A) would worsen the risk of bleeding. Applying pressure to the injection site (C) is not appropriate in this situation. Administering protamine sulfate (D) is the antidote for heparin overdose, but it is not the first action to take in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Continuous bubbling in the water seal chamber. Continuous bubbling in the water seal chamber indicates an air leak in the system, which can lead to pneumothorax or compromised lung function. Immediate intervention is required to prevent complications. Serosanguineous drainage in the collection chamber (B) is expected after thoracotomy. Intermittent bubbling in the suction control chamber (C) is normal and indicates proper suction function. Chest tube secured to the client's chest wall (D) is essential for stability and should not require immediate intervention.

Correct Answer: B

Rationale: Correct Answer: B - Take calcium supplements with meals. Rationale: 1. Calcium is essential for bone health and helps prevent osteoporosis. 2. Taking calcium with meals enhances absorption. 3. Adequate calcium intake is crucial for individuals with osteoporosis. Summary: A: Avoiding weight-bearing exercises is incorrect as they are beneficial for bone health. C: Limiting vitamin D intake is incorrect as it is needed for calcium absorption. D: Increasing caffeine intake is incorrect as it can decrease calcium absorption and worsen osteoporosis.