A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which assessment finding requires the nurse to take immediate action?

Correct Answer: D

Rationale: The correct answer is D because a sudden decrease in respiratory rate to 10 breaths per minute in a client with COPD receiving oxygen therapy can indicate respiratory depression or impending respiratory arrest, which are life-threatening emergencies. Immediate action is necessary to prevent further complications. A: An oxygen saturation of 90% is below the normal range but not an immediate concern unless it continues to decrease. B: A respiratory rate of 22 breaths per minute is within the normal range and does not require immediate action. C: Shortness of breath is common in clients with COPD and may not require immediate action unless it is severe or worsening rapidly.

Correct Answer: B

Rationale: The correct answer is B because pursed-lip breathing involves inhaling slowly through the nose and exhaling slowly through pursed lips, which helps improve lung function and relaxes the client. Choice A is incorrect because breathing in quickly through the mouth is not part of pursed-lip breathing technique. Choice C is incorrect as holding breath before exhaling is not recommended in pursed-lip breathing. Choice D is partially correct but lacks the emphasis on inhaling slowly through the nose. Therefore, the most effective statement indicating correct teaching is choice B.

Correct Answer: A

Rationale: The correct answer is A: Albuterol (Proventil). Albuterol is a short-acting beta agonist bronchodilator that provides quick relief during an asthma exacerbation by relaxing the smooth muscles in the airways. This helps to rapidly open up the airways and improve breathing. Administering albuterol first is crucial in managing acute asthma symptoms. Summary of other choices: B: Ipratropium (Atrovent) is an anticholinergic bronchodilator that is often used in combination with albuterol for asthma exacerbations, but albuterol is preferred for initial rapid relief. C: Salmeterol (Serevent) is a long-acting beta agonist used for maintenance treatment of asthma, not for acute exacerbations. D: Fluticasone (Flovent) is an inhaled corticosteroid used for long-term control of asthma symptoms and prevention of exacerbations

Correct Answer: C

Rationale: The correct answer is C. Administer oxygen to maintain saturations above 94%. In asthma exacerbation, maintaining oxygen saturation is crucial to prevent hypoxia. Oxygen therapy helps improve oxygen delivery to tissues and organs. Administering salmeterol (choice A) may help with long-term management but is not an immediate priority. Tracheal deviation assessment (choice B) is not relevant to asthma exacerbation. Performing peak expiratory flow measurements (choice D) may be helpful for monitoring asthma severity but is not the priority in this acute situation.

Correct Answer: B

Rationale: The correct answer is B: Tracheal deviation. Tracheal deviation indicates a tension pneumothorax, a life-threatening emergency that requires immediate intervention to prevent further complications. The other choices are incorrect because: A: Production of pink sputum may indicate blood-tinged sputum, which could be a sign of minor bleeding but does not require immediate intervention. C: Pain at insertion site is common after chest tube insertion and can be managed with pain medication, not necessarily requiring immediate intervention. D: Sudden onset of shortness of breath could indicate various issues, including pneumothorax, but tracheal deviation is a more specific and urgent sign that requires immediate attention.