A nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which of the following is a common sign of COPD exacerbation?

Correct Answer: B

Rationale: The correct answer is B: Increased shortness of breath. During a COPD exacerbation, airflow limitation worsens, leading to increased difficulty in breathing. This is a common sign due to air trapping and inflammation in the airways. Sudden weight gain (A) is not typically associated with COPD exacerbation. Decreased heart rate (C) is not a common sign and is more likely to occur in other conditions. Increased energy levels (D) are unlikely during a COPD exacerbation as the body is under stress from impaired lung function.

Correct Answer: A

Rationale: The correct answer is A: Administer albuterol. Albuterol is a bronchodilator that helps open airways, making it effective in treating respiratory distress. It works quickly to relieve symptoms such as shortness of breath and wheezing. Corticosteroids (B) may be used in conjunction with albuterol for severe cases, but albuterol is the immediate intervention. Providing pain relief (C) is not the primary intervention for respiratory distress. Nebulizers (D) are a delivery method for medications like albuterol, but the key intervention is administering the medication itself.

Correct Answer: A

Rationale: The correct answer is A: Administer IV fluids. The priority nursing action for a client with severe dehydration is to restore fluid volume to maintain vital organ function. Administering IV fluids is crucial in rapidly replenishing lost fluids and electrolytes. Corticosteroids (choice B) are not indicated for dehydration. Re-administering IV fluids (choice C) is redundant. Administering analgesics (choice D) is not a priority in the management of severe dehydration.

Correct Answer: A

Rationale: The correct answer is A: Administer epinephrine. In severe allergic reactions, such as anaphylaxis, epinephrine is the first-line treatment as it rapidly reverses life-threatening symptoms like airway constriction and low blood pressure. Antihistamines (choice B) may help with mild symptoms but are not sufficient for severe reactions. Applying a cold compress (choice C) is not effective in treating anaphylaxis. Encouraging deep breathing (choice D) is not appropriate as the client may have difficulty breathing due to airway constriction. Administering epinephrine is crucial to quickly stabilize the client's condition in a severe allergic reaction.

Correct Answer: D

Rationale: The correct answer is D: provide culturally sensitive and appropriate care. Including cultural information in the health assessment helps healthcare providers understand the patient's beliefs, practices, and preferences, allowing for tailored care that respects the patient's cultural background. This improves communication, trust, and overall health outcomes. Choice A is incorrect because cultural information does not necessarily identify the cause of an illness. Choice B is incorrect as it overemphasizes diagnosis without considering the patient's cultural context. Choice C is incorrect as it does not directly address the importance of cultural information in healthcare.

Correct Answer: A

Rationale: The correct answer is A because asking the client to describe the voices can help the nurse assess the situation and understand the client's experience better. This can provide valuable information for the nurse to determine the appropriate intervention or treatment. Leaving the client alone (B) may not address the underlying issue and could potentially worsen the situation. Encouraging the client to talk about the voices (C) is helpful, but asking for a description first allows for a more systematic assessment. Telling the client there are no voices (D) is dismissive and denies the client's reality, which can be harmful and ineffective in providing appropriate care.

Correct Answer: B

Rationale: The correct answer is B: Administer antibiotics. In sepsis, timely administration of antibiotics is crucial to combat the underlying infection. Antibiotics target the bacteria causing the sepsis, helping to prevent further spread and worsening of the condition. Administering IV fluids (choice A) is important to maintain blood pressure, but antibiotics take precedence in treating the infection. Providing fluids (choice C) is also important but not the priority over antibiotics. Administering oxygen (choice D) may be necessary for respiratory support in severe cases of sepsis, but it does not address the root cause of the condition like antibiotics do.

Correct Answer: C

Rationale: The correct action is to obtain baseline information first, then do a complete assessment (Choice C). This is important as it allows the healthcare provider to gather initial vital signs and key information before proceeding with a thorough assessment. By obtaining baseline information first, the healthcare provider can assess the patient's current status and identify any urgent needs requiring immediate attention. This approach helps in prioritizing the assessment and subsequent interventions. Examining only the body areas related to the problem (Choice A) may lead to missing important clues to the patient's condition. Obtaining a thorough history and physical assessment from the family (Choice B) can provide valuable information but should not be the first step in assessing the patient's immediate needs. Examining the entire body to determine if the problem is linked to something else (Choice D) is not the most efficient approach as it may delay identifying and addressing the primary issue causing shortness of breath.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the priority intervention because nitroglycerin helps dilate blood vessels, reducing chest pain in clients with heart disease. It improves blood flow to the heart, relieving ischemia. Morphine (B) can mask symptoms and should be used if pain persists after nitroglycerin. Beta blockers (C) are beneficial in chronic management but not for immediate relief. Aspirin (D) helps prevent clot formation but is not the priority in acute chest pain.