A patient with COPD reports worsening shortness of breath. What should the nurse assess first?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Oxygen saturation levels. When a patient with COPD experiences worsening shortness of breath, assessing oxygen saturation levels is critical because hypoxemia can significantly impact their condition. Low oxygen saturation levels can indicate respiratory distress and the need for supplemental oxygen therapy to improve oxygenation and alleviate symptoms. Option A) Respiratory rate and effort is important in assessing respiratory status, but in a patient with COPD experiencing worsening shortness of breath, checking oxygen saturation levels takes precedence as it provides more immediate information about oxygen exchange. Option C) Lung sounds for wheezing or crackles are important in assessing respiratory conditions, but in this case, the priority is to determine the oxygenation status of the patient. Option D) Peak expiratory flow rate is more commonly used in conditions like asthma to monitor airway obstruction, and it is not the first assessment to perform in a COPD patient with worsening shortness of breath. Educationally, understanding the prioritization of assessments in patients with COPD is crucial for nurses and healthcare providers to effectively manage and intervene in respiratory distress situations. By recognizing the significance of assessing oxygen saturation levels promptly, healthcare professionals can make timely interventions to improve patient outcomes and prevent respiratory complications.

Correct Answer: D

Rationale: In this scenario, the nurse's priority action should be to assess the patient's technique for inhaler use (Option D). Proper inhaler technique is crucial for the effective delivery of medication in asthma management. By assessing the patient's technique, the nurse can ensure that the medication is being administered correctly, maximizing its effectiveness and reducing the risk of complications or worsening symptoms. Option A is not the priority because before considering a change in treatment, it is essential to first ensure that the current treatment is being optimally administered. Option B, monitoring peak flow daily, is important in asthma management but not the priority in this situation where assessing inhaler technique is more immediate. Option C, encouraging inhaler use before exercise, is beneficial but does not address the primary concern of assessing and ensuring proper inhaler technique. Educationally, this question highlights the importance of proper inhaler technique in asthma management. It emphasizes the role of healthcare providers in assessing and educating patients on correct medication administration to improve outcomes and patient safety. Nurses play a vital role in patient education and should prioritize assessing and addressing any issues with inhaler technique to optimize treatment effectiveness.

Correct Answer: B

Rationale: In this scenario, the nurse's priority action should be to select option B, which is to assess the patient's vital signs and oxygen saturation. This choice is the most appropriate initial step because hemoptysis can indicate a potentially serious condition, such as pulmonary embolism or pneumonia, especially in a patient on anticoagulant therapy. Assessing vital signs and oxygen saturation will provide crucial information about the patient's current status and help guide further interventions. Option A (Stop anticoagulant therapy immediately) is not the priority as it may exacerbate the patient's underlying condition and should be determined by the healthcare provider. Option C (Notify the healthcare provider immediately) is important but not the immediate action needed in this case. Option D (Administer vitamin K to reverse anticoagulation) is not appropriate as the priority is to assess the patient's condition first before considering any interventions that may affect their anticoagulation status. In an educational context, understanding the rationale behind prioritizing actions in critical situations like this is essential for nurses to provide safe and effective care. It highlights the importance of quick and accurate assessment to ensure timely and appropriate interventions to address potentially life-threatening complications.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Reassure the patient this is a normal side effect. Rifampin, a medication commonly used to treat tuberculosis, can cause harmless side effects like orange-colored urine. It is essential for the nurse to reassure the patient to alleviate any concerns and ensure medication adherence. Option B) Hold the medication and notify the provider is incorrect because orange-colored urine is a known side effect of rifampin and does not warrant stopping the medication unless other concerning symptoms are present. Option C) Assess the patient for jaundice is incorrect because orange-colored urine from rifampin is not indicative of jaundice. Jaundice presents with specific symptoms like yellowing of the skin and eyes. Option D) Recommend increasing fluid intake is incorrect as it does not address the specific side effect of orange-colored urine related to rifampin use. Educationally, it is crucial for nurses to be aware of common side effects of medications to provide accurate information and support to patients. Understanding medication side effects enhances patient education, improves medication adherence, and fosters trust between healthcare providers and patients.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Wheezes. Wheezes are high-pitched, musical or whistling sounds that occur when there is narrowing or partial obstruction of the lower airways. These sounds are typically heard on both inspiration and expiration, more prominent during expiration, and are associated with conditions such as asthma, bronchitis, or COPD. Option A) Crackles are discontinuous, brief, popping sounds heard during inspiration and sometimes expiration. They are associated with conditions like pneumonia or heart failure, not with the described musical, whistling noises. Option C) Rhonchi are low-pitched, snoring or rattling lung sounds that can be heard on inspiration or expiration. They are typically caused by secretions in the larger airways and are not consistent with the high-pitched, musical sounds described. Option D) Pleural friction rub is a grating, creaking sound heard during inspiration and expiration. It is caused by inflammation of the pleural surfaces rubbing together and is not likely the cause of the described musical, whistling noises. Understanding different breath sounds is crucial for nurses to accurately assess and monitor respiratory conditions in patients. Recognizing wheezes can help in identifying and managing conditions that cause airway narrowing, leading to better patient outcomes.