A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?

Correct Answer: C

Rationale: The correct answer is C) "I've been taking Tylenol 650 mg every 6 hours for chest wall pain." This action is most effective in improving compliance with discharge teaching for a patient with COPD. Taking Tylenol for chest wall pain indicates that the patient is managing their discomfort, which can be a common symptom of COPD exacerbation. By addressing the pain, the patient is more likely to engage in activities and breathing exercises that are crucial for improving lung function and overall health. This response demonstrates the patient's understanding of self-care and symptom management, essential components of COPD management. Options A, B, and D all mention increased albuterol inhaler use, which may indicate worsening symptoms. While it is important for the nurse to address this, the primary focus should be on managing chest wall pain as it can impact the patient's ability to participate in necessary self-care activities and hinder compliance with discharge instructions. In an educational context, this question highlights the importance of holistic care for patients with COPD. It emphasizes the need to address not only respiratory symptoms but also pain management to improve patient outcomes and adherence to treatment plans. Understanding the rationale behind the correct answer reinforces the significance of comprehensive assessment and individualized care in nursing practice.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Administer IV fluids and insulin. In a patient with diabetic ketoacidosis (DKA), the priority is to address the severe dehydration and electrolyte imbalances by administering IV fluids. Insulin therapy is also crucial to reverse the ketosis and hyperglycemia seen in DKA. Option B) Administer insulin alone is incorrect because without addressing the dehydration with IV fluids, the insulin therapy alone may worsen the dehydration and electrolyte imbalances. Option C) Administer a long-acting insulin is incorrect as immediate-acting insulin is needed to address the acute hyperglycemia in DKA. Option D) Administer a platelet aggregation inhibitor is unrelated to the immediate management of DKA and does not address the underlying pathophysiology. Educational Context: Understanding the priority interventions in managing DKA is essential for nurses caring for patients with diabetes. Administering IV fluids and insulin promptly can stabilize the patient's condition and prevent severe complications. This question highlights the critical thinking needed in emergency situations to prioritize care effectively.

Correct Answer: B

Rationale: The correct answer is B) UAP help splint the patient's chest during coughing. This action is incorrect because splinting the chest during coughing can restrict chest expansion, making it harder for the patient to effectively clear secretions from the lungs, which is crucial in pneumonia. Option A is correct as assisting the patient to ambulate to the bathroom promotes mobility and can help prevent complications associated with immobility. Option C is also correct as transferring the patient to a bedside chair for meals encourages activity and promotes a sense of normalcy. Option D is correct as lowering the head of the bed to 15 degrees helps improve oxygenation by reducing the risk of aspiration. Educationally, understanding the importance of proper respiratory care in pneumonia is vital for nurses and UAP to prevent complications and promote optimal patient outcomes. It is essential to reinforce the principles of chest physiotherapy and positioning techniques to support effective airway clearance in patients with respiratory conditions like pneumonia.

Correct Answer: B

Rationale: The correct answer is B) Administer antihypertensive medication. In a hypertensive crisis, the priority intervention is to lower the dangerously high blood pressure to prevent organ damage and complications such as stroke or heart attack. Administering antihypertensive medication promptly is crucial in this situation to rapidly reduce the blood pressure to safe levels. Option A, C, and D are incorrect because although monitoring blood pressure is important, in a hypertensive crisis, immediate intervention to lower the blood pressure takes precedence over simply monitoring. Administering antihypertensive medication is the most effective way to quickly address the dangerously high blood pressure in this critical situation. From an educational standpoint, understanding the urgency of managing hypertensive crises is vital for nurses to provide safe and effective care to patients with hypertension. Recognizing the priority interventions in emergency situations like this is essential for nurses preparing for exams like the NCLEX, where quick decision-making can make a significant impact on patient outcomes.

Correct Answer: C

Rationale: The correct answer is C) Encourage deep breathing exercises. The priority intervention for a patient recovering from surgery is to prevent complications such as atelectasis and pneumonia by promoting optimal lung expansion and gas exchange. Deep breathing exercises help prevent respiratory complications by improving lung ventilation and preventing the collapse of alveoli. This intervention also promotes oxygenation and aids in preventing the formation of respiratory secretions that can lead to respiratory infections. Option A) Administer pain medications may be necessary for the patient's comfort but is not the priority in preventing respiratory complications. Option B) Administer an inhaler may be indicated for patients with respiratory conditions such as asthma but is not the priority in preventing postoperative complications related to oxygenation. Option D) Administer a nebulized corticosteroid may be used for patients with specific respiratory conditions but is not the priority in preventing general postoperative respiratory complications. Educational Context: Understanding the importance of proper oxygenation and respiratory care in postoperative patients is crucial for nurses to provide optimal care and prevent complications. Encouraging deep breathing exercises is a fundamental nursing intervention to promote lung expansion, prevent atelectasis, and maintain adequate oxygenation levels in patients recovering from surgery.