A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD). The nurse should monitor for which of the following complications?

Correct Answer: C

Rationale: The correct answer is C, hypercapnia. In COPD, impaired lung function leads to inadequate oxygen exchange, causing increased carbon dioxide levels in the blood (hypercapnia). This can result in respiratory acidosis and further exacerbate respiratory distress. Monitoring for hypercapnia is crucial in COPD management to prevent respiratory failure. Incorrect choices: A: Pulmonary embolism - While patients with COPD are at increased risk for blood clots, pulmonary embolism is not a direct complication of COPD. B: Pneumothorax - Although individuals with COPD may develop pneumothorax due to weakened lung tissue, it is not a common complication. D: Asthma attack - Asthma and COPD are distinct conditions with different pathophysiology. Asthma attacks are not a typical complication of COPD.

Correct Answer: C

Rationale: The correct answer is C: Respiratory failure. For a patient with chronic asthma, the priority complication to monitor for is respiratory failure as it can be life-threatening. Asthma is a chronic respiratory condition that can lead to severe bronchoconstriction and impaired gas exchange, potentially resulting in respiratory failure. Monitoring for signs such as increased respiratory rate, use of accessory muscles, decreased oxygen saturation, and altered mental status is crucial. Pneumothorax (A) is a possible complication but less common in chronic asthma. Hyperglycemia (B) and chronic renal failure (D) are not directly related to asthma and are not the primary complications to monitor for in this case.

Correct Answer: D

Rationale: The correct answer is D: Rotate injection sites to prevent lipodystrophy. Rotating injection sites helps prevent the development of lipodystrophy, a condition characterized by the loss of fat tissue at the injection site. This is important for maintaining consistent insulin absorption and reducing the risk of injection site complications. A: Storing insulin at room temperature is generally recommended, but it is not the most critical action for insulin administration. B: Using insulin immediately after drawing it up is not necessary for all types of insulin and may not be feasible in all situations. C: Injecting insulin into the same spot can lead to tissue damage and inconsistent insulin absorption, so it should be avoided.

Correct Answer: D

Rationale: Rationale: 1. Current health promotion activities are important to assess the patient's preventive measures. 2. At 87 years old, focusing on current habits can help identify areas for improvement. 3. Obstetrical history is irrelevant as the patient is postmenopausal. 4. Childhood illnesses are less relevant compared to current health status. 5. General health for the past 20 years may not reflect current health behaviors.

Correct Answer: B

Rationale: The correct answer is B: I will rotate injection sites to avoid tissue damage. This statement indicates proper understanding because rotating injection sites helps prevent tissue damage and ensures consistent absorption. Injecting into the same spot every time can lead to lipohypertrophy. Injecting insulin only when blood glucose is elevated is incorrect as insulin is needed regularly. Injecting into the arm for faster absorption is also incorrect, as it can lead to unpredictable absorption rates. Rotation of sites is crucial for optimal insulin absorption and to prevent complications.

Correct Answer: B

Rationale: The correct answer is B: Jaundice. In chronic liver disease, impaired liver function leads to the accumulation of bilirubin in the blood, causing jaundice. Jaundice is a common complication seen in patients with liver disease. Anemia (choice A) may occur in liver disease but is not as specific as jaundice. Hypertension (choice C) is not a direct complication of liver disease. Hypoglycemia (choice D) is more commonly associated with pancreatic disorders, not liver disease. Therefore, monitoring for jaundice is crucial in patients with chronic liver disease.

Correct Answer: A

Rationale: The correct answer is A because daily inspection helps identify issues early, preventing complications. B is incorrect as tight shoes can cause blisters. C is wrong as proper toenail trimming is essential. D is incorrect because prevention is key in diabetic foot care.

Correct Answer: C

Rationale: Step 1: Post-operative patients are at risk for developing pneumonia due to decreased lung expansion and secretion retention. Step 2: Deep breathing exercises help improve lung expansion and prevent pneumonia. Step 3: Therefore, encouraging the patient to perform deep breathing exercises is essential. Summary: - A: Avoiding deep breathing exercises is incorrect as it can lead to respiratory complications. - B: Taking shallow breaths can worsen lung function and increase the risk of pneumonia. - D: Limiting mobility can lead to complications like blood clots and pneumonia.

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's emotional state and provide reassurance. The first priority is to address the patient's anxiety and worry, as this can impact their overall well-being and ability to cope with the upcoming surgery. By assessing the emotional state, the nurse can understand the patient's concerns and provide appropriate support and reassurance. Discussing the risks and benefits (choice B) may be important but not the immediate priority. Encouraging relaxation (choice C) may not address the underlying anxiety. Calling the surgeon (choice D) is not necessary at this point as the nurse should first focus on the patient's emotional needs.