A client with asthma is assessed by a nurse and presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply)

Correct Answer: C

Rationale: Step-by-step rationale for choice C (Administer oxygen to maintain saturations greater than 94%): 1. Oxygen is crucial in managing asthma exacerbations to improve oxygen saturation levels and prevent hypoxemia. 2. Decreased pulse oxygen saturation indicates hypoxemia, which can lead to serious complications. 3. Maintaining saturations greater than 94% ensures adequate oxygenation of tissues and organs. 4. Administering oxygen promptly can help alleviate respiratory distress and improve the client's condition. Summary of why other choices are incorrect: - Choice A (Administer albuterol inhaler): While albuterol is a common medication for asthma, oxygen therapy is the priority in this scenario to address hypoxemia. - Choice B (Assess for tracheal deviation): Tracheal deviation is not typically associated with asthma exacerbations and is not the most urgent action needed in this situation. - Choice D (Perform peak expiratory flow measurements): Peak expiratory flow

Correct Answer: D

Rationale: The correct answer is D: Eat high-fiber foods to promote gastric emptying. In COPD, patients may experience slow gastric emptying due to decreased lung function. High-fiber foods can help with digestion and prevent constipation. A: Avoid drinking fluids just before and during meals - Incorrect. Hydration is important for COPD patients, but timing of fluid intake is not directly related to nutrition in this context. B: Rest before meals if experiencing dyspnea - Incorrect. While resting before meals can help with dyspnea, it is not directly related to nutrition education. C: Have about six small meals a day - Incorrect. While small frequent meals may be beneficial for some COPD patients, this is not a universal recommendation for all individuals with COPD in terms of nutrition.

Correct Answer: B

Rationale: The correct answer is B because it communicates important information to the respiratory therapist regarding the client's readiness for the PFTs. Going down to radiology indicates the client is prepared for the examination, which ensures the test can be conducted smoothly. Rationale: A: Holding the client's morning bronchodilator medication may impact test results, but this information is more relevant for the healthcare provider interpreting the results, not the respiratory therapist conducting the test. C: Physical therapy's statement about running on a treadmill is irrelevant to the PFTs and does not impact the collaboration between the nurse and respiratory therapist. D: Advising the client not to smoke for 6 hours prior to the test is important for accurate results, but this information is more pertinent for the client and healthcare provider interpreting the results, not the respiratory therapist conducting the test.

Correct Answer: A

Rationale: The correct answer is A: Increased anterior-posterior (AP) chest diameter. In COPD, air trapping causes hyperinflation of the lungs, leading to an increase in the AP chest diameter known as barrel chest. This is a classic physical finding in patients with COPD due to chronic airway obstruction. Explanation of other choices: B: Decreased respiratory rate - In COPD, patients typically have an increased respiratory rate due to difficulty breathing. C: Weight gain - Weight gain is not a typical finding in COPD and is more often associated with other medical conditions or lifestyle factors. D: Productive cough with yellow sputum - While a productive cough is common in COPD, yellow sputum is more indicative of a bacterial infection rather than COPD alone.

Correct Answer: A

Rationale: Rationale for Correct Answer A: 1. Shaking the inhaler well before use helps ensure proper mixing of the medication. 2. This action helps to distribute the medication evenly for effective delivery. 3. It prevents clogging and ensures the client receives the correct dose. 4. Shake-and-use approach is essential for optimal therapeutic benefits. Summary of Incorrect Choices: B: Inhaling rapidly may lead to improper medication delivery and increase the risk of side effects. C: Administering medication while lying down may not allow the client to inhale the medication effectively. D: Holding the inhaler too far away can result in decreased medication intake and reduced efficacy.