A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first?

Correct Answer: C

Rationale: The correct question to ask first is "Do you experience shortness of breath with basic activities?" because it directly assesses the client's current health status related to COPD, which is essential for immediate care. By prioritizing this question, the nurse can quickly evaluate the severity of the client's symptoms and determine the need for urgent intervention or adjustment of the care plan. This information is crucial for addressing the client's immediate respiratory needs and ensuring their safety. Choice A is incorrect because assessing the client's support system is important but not as urgent as evaluating their respiratory status. Choice B is also incorrect as understanding the disease is important but not as time-sensitive as assessing the client's current symptoms. Choice D is incorrect as knowing the medications the client is prescribed is important for overall care but does not address the immediate need for respiratory assessment.

Correct Answer: B

Rationale: The correct answer is B, a 52-year-old in a tripod position using accessory muscles to breathe. This client is likely experiencing respiratory distress, which is a medical emergency in COPD. The tripod position and use of accessory muscles indicate increased work of breathing and potential respiratory failure, requiring immediate assessment and intervention to prevent further deterioration. Incorrect choices: A: Smoking history is relevant but does not indicate immediate respiratory distress. C: Dependent edema and clubbed fingers suggest advanced disease but not acute respiratory distress. D: Chronic cough and thick secretions are common in COPD but do not indicate acute respiratory compromise.

Correct Answer: C

Rationale: The correct answer is C: Is the delegated task permitted by law? This is the first question the nurse must ask before delegating medication administration to an unskilled assistant. The rationale is that delegation must comply with legal regulations to ensure patient safety and avoid legal implications. If the task is not permitted by law, the nurse should not delegate it. Choice A (Has the assistant been trained to perform the task?) is important but comes after ensuring the task is legally permitted. Choice B (Have I evaluated the patients response to this task?) is about patient assessment, not legality. Choice D (Is appropriate supervision available?) is relevant but should come after confirming the task's legality.

Correct Answer: C

Rationale: The primary focus of healthcare today is health promotion (Choice C) because it emphasizes preventive measures to maintain overall well-being and reduce the burden of diseases. Health promotion involves educating individuals on healthy lifestyle choices, disease prevention, and early detection. This approach aligns with the shift towards proactive rather than reactive healthcare. Incorrect options: A: Care of acute illnesses - This option focuses on treating immediate health issues rather than preventing them. B: Care of chronic illnesses - While important, this option addresses managing ongoing conditions rather than prioritizing prevention. D: Health restoration - This choice emphasizes restoring health after illness, which is essential but not the primary focus of healthcare today.

Correct Answer: D

Rationale: The correct answer is D because discharge planning aims to ensure that the patient and their family's needs are consistently met post-discharge. This process involves assessing the patient's health status, identifying resources for continued care, and creating a plan to support the patient's transition from the healthcare facility to the home environment. By addressing the physical, emotional, and social needs of the patient and family, healthcare providers can enhance continuity of care, reduce readmission rates, and improve overall patient outcomes. Choice A is incorrect because discharge planning focuses on the post-acute care setting, not the acute care setting. Choice B is incorrect as documenting nursing care is part of the overall patient care process but not the primary rationale for discharge planning. Choice C is incorrect as discharge planning involves assessing available resources and support systems, which may or may not involve family members providing home care.