A patient who is experiencing an acute asthma attack is admitted to the emergency department. Which assessment should the nurse complete first?

Correct Answer: A

Rationale: The correct answer for the question is option A: Listen to the patient's breath sounds. This is the first assessment the nurse should complete for a patient experiencing an acute asthma attack because it provides crucial information about the patient's airway status. Auscultating breath sounds can help the nurse identify wheezing, decreased breath sounds, or other abnormalities that indicate the severity of the asthma attack. This immediate data is essential for guiding urgent treatment decisions. Option B, asking about inhaled corticosteroid use, is not the priority assessment in this situation. While knowing the patient's medication history is important, it is not the most urgent assessment when a patient is in respiratory distress. Option C, determining when the dyspnea started, is also not the first assessment to be completed. While understanding the onset of symptoms is important for the overall assessment, it does not provide immediate data on the patient's current respiratory status. Option D, obtaining the forced expiratory volume (FEV) flow rate, is a diagnostic test that may be done later to confirm the diagnosis and assess the severity of asthma. However, in the acute setting of an asthma attack, assessing breath sounds takes precedence over obtaining diagnostic test results. In an educational context, it is crucial for nursing students to understand the priority assessments in emergency situations like acute asthma attacks. By mastering the skill of quickly and accurately assessing a patient's respiratory status, nurses can initiate prompt interventions that can potentially save lives. This scenario highlights the importance of clinical judgment and critical thinking in prioritizing assessments based on the patient's immediate needs.

Correct Answer: B

Rationale: In the context of managing epistaxis (nosebleed), the correct initial nursing action is to apply direct pressure by pinching the nostrils. This is because direct pressure helps stem the bleeding by promoting clot formation and reducing blood flow to the area. While applying cold packs (Option B) may vasoconstrict blood vessels and decrease blood flow, it is not as effective as direct pressure in stopping the bleeding promptly. Cauterizing the site (Option C) or inserting nasal packing (Option D) are interventions that should only be performed by healthcare providers with appropriate training and in specific circumstances where direct pressure and other conservative measures have failed. These interventions carry risks of tissue damage, infection, and other complications if not done correctly. From an educational perspective, it is crucial for nursing students to understand the stepwise approach to managing common clinical situations like epistaxis. Emphasizing the importance of initiating simple, non-invasive measures like direct pressure first can help prevent complications and promote effective patient care. Students should also be aware of when to escalate interventions and seek assistance from healthcare professionals with advanced skills when needed. Mastering these principles enhances students' clinical judgment and prepares them to deliver safe and evidence-based care in various healthcare settings.

Correct Answer: C

Rationale: The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process.

Correct Answer: D

Rationale: The correct answer to the question, "What is the first action for a patient with symptoms of pulmonary embolism?" is to elevate the head of the bed (option D). Elevating the head of the bed is the initial intervention for a patient suspected of having a pulmonary embolism because it helps improve ventilation and oxygenation by optimizing lung expansion and perfusion matching. This position can also help decrease the workload on the heart and improve venous return, thus reducing the risk of further complications. Option A, starting oxygen, may seem like a logical choice; however, it is not the first priority in a patient with suspected pulmonary embolism. While oxygen therapy is crucial in the management of PE, optimizing the patient's position and improving gas exchange take precedence. Ordering a spiral CT scan (option B) is essential for diagnosing and confirming a pulmonary embolism; however, it is not the first action that should be taken in a patient with acute symptoms. Immediate interventions to stabilize the patient and improve oxygenation should come first. Administering anticoagulants (option C) is a critical aspect of the treatment for pulmonary embolism, but initiating anticoagulation therapy should come after the patient has been stabilized and the diagnosis confirmed. Administering anticoagulants without ensuring adequate oxygenation and proper positioning may not address the immediate needs of the patient. In an educational context, understanding the priority actions in the management of pulmonary embolism is vital for nursing students and healthcare professionals. By prioritizing interventions based on the patient's condition and the urgency of the situation, healthcare providers can ensure that patients receive timely and appropriate care, leading to better outcomes and improved patient safety.

Correct Answer: B

Rationale: **Educational Rationale:** Pursed-lip breathing is the correct answer as it is a breathing technique commonly used to help patients with COPD manage their symptoms. This technique involves inhaling slowly through the nose and exhaling through pursed lips, which creates a back pressure that helps keep the airways open. By prolonging the exhalation phase, air trapping is reduced, allowing for more effective gas exchange and improved oxygenation in patients with COPD. Option A, deep breathing, though beneficial in some situations, does not specifically address the issue of air trapping in COPD. Rapid breathing (Option C) can actually exacerbate air trapping by not allowing for complete exhalation. Shallow breathing (Option D) also does not address the need to prolong exhalation to reduce air trapping in COPD. Educationally, it is important for nursing students to understand the rationale behind different breathing techniques in managing respiratory conditions like COPD. By grasping the principles behind pursed-lip breathing, students can effectively educate and assist patients in improving their respiratory function and quality of life. Understanding the specific techniques tailored to different conditions is crucial for providing holistic care to patients with respiratory issues.