A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

Correct Answer: B

Rationale: The correct answer is B: Assess the client's respiratory status. This is the priority because the client is experiencing difficulty breathing, which could indicate a worsening of their condition. By assessing the respiratory status, the nurse can gather vital information to determine the appropriate next steps, such as adjusting the oxygen flow rate, providing respiratory treatments, or seeking further medical intervention. Increasing the oxygen flow without assessing the client's condition could potentially exacerbate the issue. Calling emergency services (choice C) may be necessary based on the assessment findings but should not be the immediate priority. Having the client cough and expectorate secretions (choice D) is important for airway clearance but is not the priority when the client is in distress.

Correct Answer: C

Rationale: The correct answer is C: Acyclovir. Acyclovir is an antiviral medication used to treat herpes infections, not tuberculosis. Rifampin, Isoniazid, and Pyrazinamide are all first-line drugs for tuberculosis treatment. Rifampin is a bactericidal agent, Isoniazid disrupts mycobacterial cell wall synthesis, and Pyrazinamide targets actively replicating bacteria. Therefore, the nurse should not plan to administer Acyclovir as it is not indicated for tuberculosis treatment.

Correct Answer: C

Rationale: The correct answer is C, negative throat culture. In viral pharyngitis, the infection is caused by a virus, not bacteria. Therefore, a throat culture would be negative as it tests for bacterial infection. Option A is incorrect as petechiae are more commonly seen in conditions like meningococcal sepsis. Option B is incorrect as a WBC count of 16,000/mm3 is more indicative of a bacterial infection. Option D is incorrect as severe hyperemia of the pharyngeal mucosa is more typical of bacterial pharyngitis, not viral.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. Preoxygenating the client with 100% oxygen for up to 3 minutes helps prevent hypoxia during suctioning. 2. COPD patients are at higher risk for hypoxia due to impaired gas exchange. 3. Preoxygenation helps maintain oxygen saturation levels and reduces the risk of complications. 4. This action supports safe and effective nasotracheal suctioning in clients with COPD and an artificial airway. Summary: - Option A: Performing suctioning for up to four passes can increase the risk of hypoxia and mucosal damage. - Option B: Applying suction to the catheter during advancement can cause trauma and increase the risk of infection. - Option D: Limiting each suction pass to 25 seconds may not provide adequate time for effective suctioning in clients with COPD and artificial airways.

Correct Answer: A

Rationale: The correct answer is A: Widened QRS complexes. Respiratory acidosis results from inadequate removal of carbon dioxide, leading to increased carbonic acid in the blood and a decrease in blood pH. This acidosis can cause electrolyte imbalances, including hyperkalemia, which can manifest as widened QRS complexes on an ECG due to the effect of high potassium levels on cardiac conduction. Hyperactive deep tendon reflexes (B) are associated with conditions such as hyperthyroidism or hypocalcemia. Bounding peripheral pulses (C) are seen in conditions like aortic regurgitation or hyperthyroidism. Warm, flushed skin (D) is more indicative of conditions like hyperthermia or sepsis.