A client with chronic obstructive pulmonary disease (COPD) is experiencing respiratory distress. Which intervention should the nurse implement first?

Correct Answer: C

Rationale: The correct answer is to position the client in a high Fowler's position first. This helps improve lung expansion and oxygenation, making it the priority intervention for a client with respiratory distress. Administering bronchodilators or obtaining an ABG sample can wait until the client's oxygenation is improved. Pursed-lip breathing can be helpful, but positioning is more critical in this situation.

Correct Answer: C

Rationale: The correct answer is C: Colchicine. Colchicine is used to treat acute gout attacks by reducing inflammation and pain. It works by decreasing the inflammatory response to urate crystals in the joints. Aspirin (choice A) is not recommended for gout treatment as it can worsen symptoms. Allopurinol (choice B) and Probenecid (choice D) are used for long-term management of gout by reducing uric acid levels and preventing future attacks, not for acute attacks. Colchicine is the appropriate choice for treating the client's acute gout symptoms.

Correct Answer: B

Rationale: The correct answer is B: Avoid taking anticoagulant medications for one week before the biopsy. This is essential to prevent excessive bleeding during and after the procedure. Chronic kidney disease patients are at higher risk of bleeding due to impaired kidney function. A: Maintaining a low-protein diet is not directly related to the biopsy procedure and is not necessary. C: Drinking plenty of fluids may be beneficial for renal function but is not a specific pre-procedure instruction for a renal biopsy. D: Taking routine medications with water is important, but specific instructions regarding anticoagulant medications are more critical in this case.

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: D

Rationale: The correct answer is D: Decreased vital capacity. This finding indicates respiratory muscle weakness, which can lead to respiratory failure in Guillain-Barr© syndrome. Immediate action is needed to prevent respiratory compromise. Choice A is a common finding in Guillain-Barr© and does not require immediate action. Choice B is characteristic of Guillain-Barr© and should be monitored but not the most urgent. Choice C could indicate other issues but is not as critical as respiratory compromise.

Correct Answer: C

Rationale: Correct Answer: C - Administer vitamin K as prescribed. Rationale: 1. Cirrhosis impairs liver function, leading to decreased synthesis of clotting factors, increasing the risk of bleeding. 2. Vitamin K is essential for synthesizing clotting factors; administering it helps improve clotting ability. 3. Monitoring for infection (A) is important but does not directly address the clotting issue. 4. Limiting protein intake (B) is not necessary for bleeding prevention in cirrhosis. 5. Encouraging fluid intake (D) is important for overall health but does not specifically reduce the risk of bleeding.

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: C

Rationale: The correct answer is C: Hemoglobin level. In chronic renal failure, the kidneys may not produce enough erythropoietin, leading to anemia. Epoetin alfa stimulates red blood cell production. Therefore, reviewing the hemoglobin level is crucial to determine the need for the medication. Incorrect choices: A: Blood urea nitrogen (BUN) and B: Creatinine clearance are indicators of kidney function but not directly related to monitoring the effectiveness of epoetin alfa. D: Serum potassium is important in renal failure but not specifically needed to review before administering epoetin alfa.

Correct Answer: C

Rationale: The correct answer is C: White blood cell count of 2,000/mm3. A low white blood cell count indicates leukopenia, which increases the risk of infection in clients receiving chemotherapy. Hemoglobin level (choice A) and platelet count (choice B) are not directly related to infection risk. Serum creatinine level (choice D) is related to kidney function, not infection risk. In summary, a low white blood cell count is the most critical indicator for infection risk in clients undergoing chemotherapy.