A nurse is assessing a patient whose respiratory disease in characterized by chronic hyperinflation of the lungs. What would the nurse most likely assess in this patient?

Correct Answer: C

Rationale: Chronic hyperinflation, typical in COPD with emphysema, results from air trapping due to alveolar destruction and loss of elastic recoil, reshaping the thorax into a barrel chest expanded anteroposterior diameter from flattened diaphragm and elevated ribs. The nurse assesses this physical sign via inspection, noting a rounded chest contour, reflecting advanced disease. Oxygen toxicity occurs with prolonged high O2 therapy, not hyperinflation itself. Chronic chest pain isn't a COPD feature unless from comorbidities (e.g., pleurisy), as emphysema involves dyspnea over pain. Long, thin fingers (arachnodactyly) relate to Marfan syndrome, not lung disease. Barrel chest's presence informs the nurse of disease severity, guiding interventions like breathing techniques or oxygen titration to manage chronic respiratory compromise.

Correct Answer: C

Rationale: A patient's statement about using a long-acting beta2-agonist (LABA, e.g., salmeterol) ‘each time I feel an asthma attack coming on' signals a need for further education, as LABAs are for maintenance, not rescue. LABAs prevent bronchospasm over 12-24 hours, not acutely relieving symptoms that's the role of short-acting beta-agonists (e.g., albuterol). Misuse risks delaying effective treatment, worsening attacks. Tachycardia is a known side effect, correctly noted. LABAs do prevent exercise-induced asthma, a valid benefit. Tolerance (less effectiveness over time) can occur, a fair concern. The nurse must clarify LABA's prophylactic role twice-daily dosing versus rescue inhalers, ensuring the patient's action plan prevents severe exacerbations, per asthma management standards.

Correct Answer: C

Rationale: A left femoral peripheral nerve block, used in knee arthroplasty, targets the femoral nerve, numbing the anterior thigh, knee, and medial leg, so decreased sensation in the left leg is an expected finding. This regional anesthesia blocks sensory pathways, reducing postoperative pain in the targeted area without affecting systemic consciousness. Decreased pulse, cool toes, or cyanosis suggest vascular compromise, not nerve block effects, and would indicate complications like arterial injury. Pain in the left foot contradicts the block's purpose effective anesthesia should prevent this unless it's wearing off or incomplete. The nurse's assessment confirms the block's efficacy, ensuring pain control and monitoring for unintended motor or circulatory issues, per regional anesthesia standards.

Correct Answer: B

Rationale: The nurse delegates to the nursing assistant to inform if patients are unwilling to perform exercises, leveraging their scope to observe and report while retaining oversight for follow-up. Teaching and demonstrating exercises require nursing judgment, beyond the assistant's role. Documentation in the medical record is a nursing responsibility for legal accuracy. Doing nothing neglects patient care needs. This delegation ensures the nurse addresses barriers like pain or reluctance, maintaining exercise compliance to prevent complications like thrombosis or atelectasis, per collaborative care principles.

Correct Answer: B

Rationale: Securing table attachments with foam padding minimizes skin breakdown by cushioning pressure points (e.g., heels, sacrum) during prolonged intraoperative positioning. Unusual positions for surgical access can cause abrasions or ulcers without protection padding distributes weight, preserving circulation. Bathing pre-surgery reduces microbes, not pressure injury. Adjusting the patient risks sterility breaches and airway disruption, impractical intraoperatively. Measuring time monitors risk but doesn't prevent breakdown. The nurse's use of padding aligns with skin integrity protocols, ensuring safety during immobility under anesthesia.