A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what he should eat for breakfast, what should the nurse recommend?

Correct Answer: B

Rationale: The correct answer is B: A cup of nonfat yogurt with granola, and a handful of dried apricots. This choice is the best option because it provides a balance of nutrients that can support the patient's poor tissue perfusion due to hypertension. Nonfat yogurt is low in saturated fats, granola offers fiber and nutrients, and dried apricots provide potassium which is beneficial for managing blood pressure. Choice A is incorrect because whole milk and a banana can be high in saturated fats and sugars, which can be detrimental to someone with hypertension. Choice C is also not ideal as butter and cottage cheese can be high in saturated fats and sodium, which can worsen hypertension. Choice D is the least suitable option as sausage, cheese, and onions are high in saturated fats and sodium, which can negatively impact blood pressure levels.

Correct Answer: B

Rationale: The correct answer is B: Keep the head of the bed elevated to 45 degrees. This is the highest priority action because it helps improve ventilation and oxygenation in clients with COPD by reducing the work of breathing. Elevating the head of the bed promotes optimal lung expansion and decreases the risk of respiratory distress. Choice A: Encouraging ambulation is important for overall health; however, maintaining proper positioning for respiratory function takes precedence in COPD clients. Choice C: While it is important to monitor and assist clients for safety reasons, maintaining proper positioning for respiratory function is more critical in this scenario. Choice D: While assisting with activities of daily living is essential, maintaining proper positioning for respiratory function is crucial in managing COPD symptoms.

Correct Answer: C

Rationale: The correct answer is C: Ensuring proper endotracheal tube placement. This is the priority assessment because incorrect placement can lead to inadequate oxygenation and ventilation. Step 1: Verify tube placement by auscultating bilateral breath sounds. Step 2: Confirm placement with chest x-ray. Step 3: Assess for signs of respiratory distress to ensure adequate oxygenation. Choices A, B, and D are incorrect because they are important assessments but not the priority in this scenario. Checking for barotrauma (A) and monitoring for ventilator-associated pneumonia (B) are important considerations, but ensuring proper tube placement takes precedence. Assessing for sedation-related complications (D) is also crucial but not the priority assessment in this case.

Correct Answer: C

Rationale: The correct answer is C: Tachycardia. Albuterol is a beta-2 agonist bronchodilator that can stimulate beta-2 receptors in the heart, leading to tachycardia as a common side effect. This occurs due to the drug's sympathomimetic effects on the heart, increasing heart rate. Bradycardia (A) is not a typical side effect of albuterol. Hypoglycemia (B) is not a direct side effect of albuterol use. Hypotension (D) is less common with albuterol and is more associated with beta-1 receptor effects.

Correct Answer: B

Rationale: The correct answer is B: Checking for kinks or obstructions in the tubing. This is the priority action because high-pressure alarms indicate a blockage or restriction in the ventilator circuit, which can lead to inadequate ventilation and hypoxia. By checking for kinks or obstructions first, the nurse can address the immediate issue causing the alarm and ensure the client's safety. Silencing the alarm and notifying the healthcare provider (Choice A) can be done after addressing the alarm cause. Increasing oxygen flow rate (Choice C) may not resolve the issue and could potentially worsen the situation. Suctioning the client immediately (Choice D) is not appropriate without first identifying and addressing the cause of the high-pressure alarms.