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

Correct Answer: A

Rationale: The correct answer is A: Administering bronchodilators as prescribed. Rationale: 1. Bronchodilators help dilate the airways, improving airflow in COPD patients. 2. Priority is to address the underlying respiratory issue. 3. Bronchodilators are a standard treatment for managing COPD symptoms. 4. Improving airway patency is crucial in COPD exacerbations. Summary: - B: Encouraging avoidance of physical activity is incorrect as it can lead to deconditioning. - C: Providing supplemental oxygen is important but not the priority in this case. - D: Monitoring for acute kidney injury is unrelated to COPD management.

Correct Answer: C

Rationale: The correct answer is C: Neutropenia. Chemotherapy can suppress bone marrow function, leading to a decrease in neutrophils (a type of white blood cell), causing neutropenia. This increases the risk of infection. Monitoring for signs of infection is crucial in patients receiving chemotherapy to prevent serious complications. Anemia (A) is a common side effect of chemotherapy but is not directly related to infection risk. Hyperkalemia (B) and hypocalcemia (D) are less likely to be immediate complications of chemotherapy compared to neutropenia.

Correct Answer: A

Rationale: The priority nursing intervention for a client with asthma experiencing wheezing is to administer oxygen. Wheezing indicates airway constriction and decreased oxygenation, making oxygen crucial for adequate tissue perfusion. Administering oxygen helps improve oxygen levels, alleviate respiratory distress, and prevent hypoxemia. Applying a bronchodilator (Choice B) may be beneficial after oxygen is administered. Applying a cold compress (Choice C) is not indicated for asthma exacerbations, and encouraging deep breathing (Choice D) may worsen respiratory distress in a client with wheezing. In summary, administering oxygen is the priority intervention to address the immediate respiratory needs of the client with asthma and wheezing.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): Promoting activity is the most prioritized nursing intervention for a client with CHF. Activity helps improve cardiac function, decreases fluid accumulation, and enhances overall cardiovascular health. It also prevents complications like muscle weakness and deconditioning. It is crucial in managing CHF symptoms and improving the client's quality of life. Summary of Incorrect Choices: A: Administering diuretics helps in reducing fluid overload but does not address the underlying issue of improving cardiac function through physical activity. B: Limiting fluid intake is important, but promoting activity takes precedence as it directly impacts cardiac function and fluid accumulation. D: Maintaining fluid balance is necessary but is a broad concept that includes various interventions, with promoting activity being more focused and critical in CHF management.

Correct Answer: B

Rationale: The correct answer is B because conveying respect for differences helps build trust and encourages patients to share their perspectives openly. This fosters a positive patient-provider relationship and enhances communication. Choice A is incorrect as patients have unique behaviors. Choice C is incorrect as cultural expectations do not fully explain individual differences. Choice D is incorrect as expressing one's culture is not solely dependent on exposure to Canadian values.

Correct Answer: C

Rationale: The correct answer is C: Use a professional interpreter or translation services to communicate effectively. This is the best action because it ensures accurate communication and understanding between the nurse and the patient. Professional interpreters are trained to accurately convey information while respecting cultural nuances. Explanation for why the other choices are incorrect: A: Using medical jargon can confuse the patient further and hinder effective communication. B: Speaking loudly and slowly can come across as patronizing and does not address the language barrier. D: Relying on the patient's family for translation can lead to miscommunication or breaches of patient confidentiality.

Correct Answer: A

Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating sepsis as they help to fight the underlying infection causing the condition. Administering antibiotics promptly can prevent the infection from spreading and worsening. Fluids (choices B and C) are important for treating sepsis to maintain blood pressure and support organ function, but antibiotics are the primary intervention to target the infection. Administering oxygen (choice D) may be necessary to support respiratory function in septic patients, but it is not the most effective action to address the underlying infection.

Correct Answer: B

Rationale: The correct answer is B: Clanging. Clanging refers to the phenomenon where words are chosen based on sound rather than meaning. In this case, the patient's speech demonstrates a pattern of words that rhyme or have similar sounds, despite lacking coherence or logical connection. This behavior is commonly seen in individuals with conditions like schizophrenia. Incorrect choices: A: Blocking - Blocking refers to sudden interruption or cessation of speech. This does not apply to the scenario described. C: Echolalia - Echolalia involves repetition of words or phrases spoken by others, not self-generated word patterns like in the scenario. D: Neologism - Neologism refers to the creation of new words or phrases with unique meanings, which is not reflected in the patient's speech pattern.

Correct Answer: D

Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.