An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best?

Correct Answer: A

Rationale: The correct answer is A: Assess the client's lung sounds. This is the best action because coughing during a meal with a tracheostomy could indicate aspiration, which can lead to respiratory complications. Assessing lung sounds can help determine if there are any signs of respiratory distress. B: Assign a different AP to the client - This is not the best action as the priority is to assess the client's condition first. C: Report the AP to the manager - This is not the best action as the immediate concern is the client's well-being and assessing their condition. D: Request thicker liquids for meals - This is not the best action as it does not address the potential respiratory issue the client may be experiencing.

Correct Answer: D

Rationale: Step 1: Chronic stable angina is chest pain relieved by rest or nitroglycerin due to reduced blood flow to the heart. Step 2: Choice D indicates pain relieved by nitroglycerin, a hallmark of angina. Step 3: Choices A, B, and C do not specifically confirm angina diagnosis. Summary: Choice D is correct as it directly aligns with the characteristic relief of angina pain with nitroglycerin. Choices A, B, and C do not provide direct confirmation of chronic stable angina.

Correct Answer: C

Rationale: The correct answer is C because assessing the patient's intake, output, and daily weight provides direct information on fluid balance. Intake measures fluid coming in, output measures fluid going out, and daily weight reflects changes in total body water. Blood pressure and pulse (A) are affected by various factors and may not solely indicate fluid status. Serum potassium and sodium levels (B) are affected by multiple factors, not just fluid volume. Measurements of abdominal girth and calf circumference (D) are more specific to assessing for fluid retention in certain areas, not overall fluid volume status.

Correct Answer: C

Rationale: The correct question to ask first is "Do you experience shortness of breath with basic activities?" because it directly assesses the client's current health status related to COPD, which is essential for immediate care. By prioritizing this question, the nurse can quickly evaluate the severity of the client's symptoms and determine the need for urgent intervention or adjustment of the care plan. This information is crucial for addressing the client's immediate respiratory needs and ensuring their safety. Choice A is incorrect because assessing the client's support system is important but not as urgent as evaluating their respiratory status. Choice B is also incorrect as understanding the disease is important but not as time-sensitive as assessing the client's current symptoms. Choice D is incorrect as knowing the medications the client is prescribed is important for overall care but does not address the immediate need for respiratory assessment.

Correct Answer: B

Rationale: The correct answer is B: Cool, clammy skin. Following a myocardial infarction, the client may experience hypotension due to decreased cardiac output. Cool, clammy skin indicates poor peripheral perfusion, a common manifestation of hypotension. This finding suggests inadequate blood flow to the skin. The other choices are incorrect because: A: A heart rate of 120 beats/min may indicate tachycardia, which is a compensatory mechanism to maintain cardiac output in response to hypotension. C: An oxygen saturation of 90% is below the normal range but is not a typical assessment finding related to hypotension after a myocardial infarction. D: A respiratory rate of 8 breaths/min is abnormally low but not directly related to hypotension post-myocardial infarction.