A client with a history of COPD reports increasing dyspnea. What is the nurse's priority assessment?

Correct Answer: A

Rationale: The correct answer is A: Oxygen saturation levels. This is the priority assessment because in a client with a history of COPD experiencing increasing dyspnea, it is crucial to assess their oxygen saturation levels to determine if they are hypoxic. Hypoxia can exacerbate COPD symptoms and lead to respiratory distress. Monitoring oxygen saturation levels helps in assessing the effectiveness of respiratory interventions. Choice B (Heart rate and blood pressure) is important but not the priority as hypoxia can directly impact these vital signs. Choice C (Capillary refill time) is more relevant for assessing perfusion in cardiovascular conditions. Choice D (Level of consciousness) is important but assessing oxygen saturation levels takes precedence in a client with COPD and worsening dyspnea.

Correct Answer: C

Rationale: The correct answer is C: Keep the patient NPO until the gag reflex returns. After a bronchoscopy with biopsy, the patient's throat and gag reflex may be impaired due to the procedure and anesthesia. Keeping the patient NPO until the gag reflex returns is crucial to prevent aspiration and ensure safe swallowing. Encouraging clear liquids (A) may pose a risk of aspiration if the gag reflex is not intact. Bed rest (B) may not be necessary unless there are specific complications. Maintaining the head of the bed elevated (D) is generally advised for respiratory comfort but is not the immediate priority post-procedure.

Correct Answer: B

Rationale: The correct answer is B: Albuterol (Ventolin HFA) 2.5 mg per nebulizer. In an acute asthma attack, the priority is to quickly open the airways to improve breathing. Albuterol is a short-acting beta agonist that acts rapidly to bronchodilate and relieve bronchospasm. Administering it via nebulizer allows for fast delivery and effective relief. Methylprednisolone (A) is a corticosteroid that helps reduce inflammation but works more slowly and is typically given after initial bronchodilator therapy. Salmeterol (C) is a long-acting beta agonist not used for immediate relief in acute attacks. Ipratropium (D) is an anticholinergic that can also help with bronchodilation but is not the first-line treatment for acute asthma exacerbations.

Correct Answer: C

Rationale: The correct answer is C because taking antibiotics for influenza is ineffective as influenza is a viral infection, not bacterial. Antibiotics only work against bacteria. Step 1: Influenza is caused by a virus. Step 2: Antibiotics do not treat viral infections. Step 3: Taking antibiotics for influenza will not help. Summary: A, B, and D are correct strategies for reducing influenza transmission, while C is incorrect as antibiotics are not appropriate for treating influenza.

Correct Answer: B

Rationale: The correct answer is B: Monitor for continuous bubbling in the water-seal chamber. This is the priority intervention because continuous bubbling indicates an air leak, which can lead to a pneumothorax. By monitoring for bubbling, the nurse can detect and address the issue promptly. Clamping the chest tube during transport (choice A) is incorrect as it can lead to a tension pneumothorax. Encouraging coughing and deep breathing (choice C) is important for respiratory hygiene but not the priority. Keeping the drainage system at the patient's chest level (choice D) is crucial for proper drainage but does not address the immediate concern of detecting an air leak.