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

Correct Answer: A

Rationale: The correct answer is A: Breath sounds and oxygen saturation. In COPD, monitoring respiratory status is crucial due to impaired gas exchange. Assessing breath sounds helps identify any adventitious sounds like wheezing or crackles, indicating respiratory distress. Oxygen saturation reflects oxygenation status, vital for patients with COPD prone to hypoxemia. Nutritional intake and weight (B), bowel sounds and abdominal girth (C), and urine output and skin integrity (D) are important but secondary assessments in this case. Nutritional status and weight are important for overall health, bowel sounds and abdominal girth are related to gastrointestinal function, and urine output and skin integrity are indicators of hydration and overall skin health, respectively. However, in a patient with COPD, the priority is ensuring adequate oxygenation and respiratory function.

Correct Answer: C

Rationale: The correct answer is C: Severity. In the PQRSTU mnemonic, "S" stands for Severity, which refers to the intensity or seriousness of the symptoms experienced by the patient. This is crucial in assessing the impact of the problem on the patient's health and well-being. Incorrect choices: A: Swelling - Swelling is a physical symptom and does not encompass all aspects of the patient's perception. B: Subjectivity - While the patient's subjective experience is important, it does not specifically refer to severity. D: Symptoms - While symptoms are part of the patient's perception, the "S" in PQRSTU specifically focuses on the severity of those symptoms.

Correct Answer: B

Rationale: The correct answer is B: a set of rules. Novice nurses rely on established guidelines and protocols to make decisions as they lack the experience to rely solely on intuition or journal articles. Rules provide structure and consistency in decision-making, reducing the margin of error. Intuition (choice A) may not be reliable without prior experience. Journal articles (choice C) can be overwhelming and may not directly apply to the specific situation. Advice from supervisors (choice D) can be helpful but may not always be readily available, and it's important for novice nurses to develop their own decision-making skills.

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: B

Rationale: The correct answer is B: To monitor the amount of airway obstruction. A peak flow meter is used to measure how well the patient can exhale air from the lungs, indicating the degree of airway obstruction in conditions like asthma. By monitoring peak flow readings, the nurse can assess the severity of the patient's asthma and adjust treatment accordingly. Choices A, C, and D are incorrect: A: To measure the amount of oxygen in the blood - This is the function of a pulse oximeter, not a peak flow meter. C: To measure the frequency of inhaler use - This is not the primary purpose of a peak flow meter, which is specifically used to monitor airway obstruction. D: To track blood glucose levels - This is the function of a glucometer, not a peak flow meter used for asthma management.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. When a client is experiencing respiratory distress, the priority intervention is to open up the airways to improve breathing. Bronchodilators help relax and widen the airways, making it easier for the client to breathe. This intervention addresses the immediate need for improved respiratory function. Administering corticosteroids (choices B and C) may be beneficial in some cases but is not the priority in acute respiratory distress. Monitoring respiratory rate (choice D) is important but does not directly address the underlying issue of airway constriction in respiratory distress.

Correct Answer: B

Rationale: The correct answer is B: Advise the patient to sleep with the head of the bed elevated. Elevating the head of the bed helps prevent stomach acid from flowing back into the esophagus during sleep, reducing GERD symptoms. This position also promotes better digestion. Choices A, C, and D are incorrect because encouraging large meals before bedtime can worsen GERD symptoms, drinking caffeinated beverages can trigger acid reflux, and avoiding antacids can lead to inadequate symptom management.

Correct Answer: A

Rationale: The correct answer is A: Giving the client the best quality of life possible. Palliative care aims to improve quality of life for individuals facing serious illnesses through symptom management, emotional support, and enhancing overall well-being. It focuses on promoting comfort and relief from pain, rather than curing the illness. Choice B is also relevant as palliative care considers the holistic needs of the individual. Choices C and D are incorrect as palliative care is not restricted to end-of-life care only and involves supporting both the patient and their family throughout the illness journey.

Correct Answer: C

Rationale: The correct answer is C: Functional. Functional assessment focuses on roles and relationships of the client by evaluating how well they can perform daily activities and interact with others. This type of assessment provides valuable insights into a client's overall well-being and ability to function independently. Incorrect choices: A: Body systems - This type of assessment focuses on the physical structures and functions of the body, not on the client's roles and relationships. B: Head to toe - This refers to a comprehensive physical examination from head to toe, which does not specifically address the client's roles and relationships. D: Focused - This type of assessment targets a specific issue or concern, but it may not necessarily delve into the client's roles and relationships.