A nurse is caring for a client who reports sudden shortness of breath and chest pain. Which of the following should the nurse suspect?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Pulmonary embolism. A nurse should suspect a pulmonary embolism when a client presents with sudden shortness of breath and chest pain. A pulmonary embolism occurs when a blood clot travels to the lungs, obstructing blood flow and causing these symptoms. Option B) Acute myocardial infarction is less likely in this case because chest pain in a heart attack is typically described as pressure or squeezing, not worsened by breathing like in a pulmonary embolism. Option C) Pleural effusion typically presents with gradual onset of shortness of breath and chest pain, not sudden as described in the question scenario. Option D) Pneumothorax may present with sudden shortness of breath, but the absence of chest pain or the location of the pain being different makes it less likely than a pulmonary embolism. Educationally, understanding these distinctions is crucial for nurses to provide prompt and accurate care in emergency situations, ensuring timely interventions for conditions like pulmonary embolism that require immediate attention to prevent serious complications.

Correct Answer: C

Rationale: In managing a client prescribed with a bronchodilator and a corticosteroid inhaler, the nurse should provide essential education to ensure optimal therapeutic outcomes. The correct answer, option C, instructs the client to rinse their mouth after using the corticosteroid inhaler. This is crucial because corticosteroids can increase the risk of oral fungal infections, so rinsing the mouth helps prevent this complication. Option A, instructing to use the corticosteroid inhaler first, is incorrect because bronchodilators should be used before corticosteroids to open the airways and allow better penetration of the corticosteroid medication. Option B, waiting 5 minutes between using the two inhalers, is not recommended as there is no specific time interval requirement between using bronchodilators and corticosteroids. Option D, not using the bronchodilator if symptoms improve, is also incorrect as bronchodilators provide immediate relief of symptoms and should be used as needed regardless of symptom improvement. In an educational context, it is important for nurses to emphasize the correct sequence of using inhalers, the importance of rinsing the mouth after corticosteroid inhaler use, and the need for continued bronchodilator use as prescribed for effective symptom management in clients with respiratory conditions. This knowledge empowers clients to properly manage their medications and reduce the risk of adverse effects.

Correct Answer: B

Rationale: In assessing a client with suspected pneumothorax, the finding most indicative of this condition is decreased breath sounds on the affected side (Option B). This is because a pneumothorax involves air accumulating in the pleural space, causing lung collapse. As a result, breath sounds are diminished or absent over the affected area. Option A, dullness on percussion, is associated with conditions like pleural effusion, not pneumothorax. Option C, barrel-shaped chest, is typically seen in patients with chronic obstructive pulmonary disease (COPD). Option D, cyanosis of lips and fingertips, is a sign of hypoxia and is not specific to pneumothorax. In an educational context, understanding the specific clinical manifestations of pneumothorax is crucial for nurses to provide timely and accurate care. Recognizing decreased breath sounds in a patient with suspected pneumothorax can prompt immediate intervention, such as notifying the healthcare provider for further evaluation and treatment. This knowledge enhances patient safety and outcomes in clinical practice.

Correct Answer: A

Rationale: In this scenario, option A, "Decreased wheezing on auscultation," suggests that the albuterol medication is effective for the client with asthma. Wheezing is a common symptom of asthma caused by airway constriction and inflammation. Albuterol is a bronchodilator that works to relax the airway muscles, leading to improved airflow and decreased wheezing. Therefore, a reduction in wheezing indicates that the medication is effectively dilating the airways and improving the client's breathing. Options B, C, and D are incorrect. An increased heart rate (option B) could indicate a side effect of albuterol, but it does not necessarily indicate the effectiveness of the medication in treating asthma. A decreased oxygen saturation (option C) would be a concerning finding, as it suggests inadequate oxygenation despite treatment. Mild hand tremors (option D) are a known side effect of albuterol but do not directly reflect the medication's effectiveness in treating asthma. Educationally, it is crucial for nurses to understand the expected outcomes and responses to specific medications used in treating respiratory conditions like asthma. Monitoring for clinical indicators of effectiveness, such as improved respiratory function like decreased wheezing, helps nurses assess the client's response to treatment and make informed decisions about ongoing care and interventions. This knowledge enhances patient safety and improves overall health outcomes for individuals with asthma.

Correct Answer: B

Rationale: In teaching a client with pulmonary fibrosis about energy conservation techniques, the most effective strategy is option B) Sitting while performing tasks like cooking. This is because sitting while engaging in activities reduces the energy expenditure and strain on the respiratory system, which is crucial for individuals with compromised lung function like pulmonary fibrosis. By sitting, the client can conserve energy and reduce the workload on their lungs, thus preventing excessive fatigue and shortness of breath. Option A) Performing all activities in the morning may not be the most effective strategy as energy levels fluctuate throughout the day, and the client may still experience fatigue when performing tasks later in the day. Option C) Increasing physical activity to build stamina is not suitable for individuals with pulmonary fibrosis because excessive physical exertion can lead to increased oxygen demand, exacerbating respiratory distress. Option D) Avoiding rest breaks to maintain momentum is counterproductive as rest breaks are essential for individuals with pulmonary fibrosis to prevent overexertion and conserve energy. Educationally, it is important to emphasize the rationale behind energy conservation techniques for clients with pulmonary fibrosis to help them manage their condition effectively and improve their quality of life. By providing specific strategies like sitting while performing tasks, nurses can empower clients to better manage their symptoms and reduce the impact of pulmonary fibrosis on their daily activities.