A nurse is teaching a newly licensed nurse about pulmonary function tests. The nurse should include which of the following is the vital capacity?

Correct Answer: B

Rationale: The correct answer is B because vital capacity is the maximum volume of air that can be expired after a maximum inspiration. It consists of inspiratory reserve volume, tidal volume, and expiratory reserve volume. Choice A is incorrect because it describes tidal volume. Choice C is incorrect because it refers to inspiratory reserve volume. Choice D is incorrect because it describes total lung capacity, which includes vital capacity plus residual volume.

Correct Answer: A

Rationale: The correct answer is A: Auscultate the lung sounds. This should be done first to assess the severity of wheezing and determine if the client's airway is compromised. It helps in making immediate decisions for appropriate interventions like administering bronchodilators or oxygen therapy. Documenting the respiratory rate (B) can be done after assessing lung sounds. Obtaining oxygen saturation (C) is important but not the first priority. Checking capillary refill (D) is not relevant in this situation and can be done later. Overall, assessing lung sounds is crucial in managing a client with asthma and wheezing.

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.