An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement?

Correct Answer: D

Rationale: In this scenario, the correct intervention is option D: Assist her to an upright position. Rationale: Assisting the older adult woman to an upright position is the most appropriate intervention because it helps optimize ventilation and oxygenation by reducing the work of breathing and improving lung expansion. This position allows for better lung expansion, which can alleviate shortness of breath and enhance oxygenation. It also helps in the management of COPD exacerbations by facilitating better airflow and mucus clearance. Explanation of Incorrect Options: A) Administer a prescribed sedative: Administering a sedative can further depress the respiratory drive and exacerbate respiratory distress in a patient with COPD. B) Encourage client to drink water: While staying hydrated is important, it does not directly address the respiratory distress and anxiety the patient is experiencing. C) Apply a high-flow venturi mask: While oxygen therapy may be necessary, in this case, addressing the patient's positioning is a more immediate and appropriate intervention before considering oxygen therapy. Educational Context: Understanding the appropriate interventions for patients with COPD exacerbations is crucial for nurses caring for individuals with respiratory conditions. Positioning plays a key role in optimizing respiratory function and should be one of the initial interventions in managing respiratory distress. Nurses need to be able to assess and implement appropriate interventions promptly to ensure optimal patient outcomes in cases of respiratory distress.

Correct Answer: C

Rationale: In this scenario, the correct nursing problem to include in the client's plan of care is "Fluid volume excess" (Option C). The client's low serum sodium level of 117 mEq/L (hyponatremia) indicates a potential imbalance of fluids in the body. Hyponatremia can occur in lung cancer patients due to syndrome of inappropriate antidiuretic hormone secretion (SIADH), a common paraneoplastic syndrome associated with certain malignancies like lung cancer. This syndrome leads to the retention of water and dilution of sodium levels in the blood, resulting in fluid volume excess. Option A, "Altered urinary elimination," is incorrect as the primary issue in this case is not related to the client's ability to eliminate urine but rather to the imbalance of fluid and electrolytes. Option B, "Impaired gas exchange," is also incorrect as the client's symptoms of weakness and hyponatremia are not primarily indicative of respiratory issues. Option D, "Decreased cardiac output," is not the most appropriate choice as the client's symptoms and lab results are more suggestive of a fluid imbalance rather than a cardiac output problem. Educationally, understanding the connection between lung cancer, hyponatremia, and fluid volume excess is crucial for nursing practice. Nurses must recognize the signs and symptoms of electrolyte imbalances in cancer patients and be able to prioritize nursing interventions to address fluid volume excess effectively. By selecting Option C as the correct answer, nurses can implement appropriate interventions such as fluid restriction, monitoring electrolyte levels, and collaborating with the healthcare team to manage the underlying cause of hyponatremia in the client with lung cancer.

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to take is to continue to monitor the fingers until the color returns to normal (Option D). This is because the client is exhibiting symptoms of Raynaud phenomenon, a condition characterized by vasospasm of the blood vessels in response to cold or stress. In Raynaud phenomenon, fingers first turn pale due to reduced blood flow, then cyanotic due to lack of oxygen, and finally red with a burning sensation as blood flow returns. Applying a cool compress (Option A) would exacerbate the vasoconstriction and worsen the symptoms. While monitoring oxygen saturation with a pulse oximeter (Option B) is important in some cases, it is not the priority here as the issue is related to vasospasm rather than decreased oxygenation. Reporting the finding to the healthcare provider (Option C) may be necessary eventually, but immediate intervention to address the vasospasm is more crucial in this acute situation. Educationally, this question highlights the importance of understanding the pathophysiology of Raynaud phenomenon and the appropriate nursing interventions. It underscores the need for nurses to recognize and respond to vascular disorders promptly to prevent further complications and provide optimal care for clients with such conditions.

Correct Answer: B

Rationale: The correct answer is option B) A 65-year-old fair-skinned male who is a construction worker. Fair-skinned individuals have less melanin in their skin, making them more susceptible to skin damage from UV radiation, which increases the risk of developing skin cancer. Additionally, working outdoors as a construction worker exposes him to prolonged sun exposure, further increasing his risk. Option A) A 16-year-old dark-skinned female who tans in tanning beds once a week is at risk for skin damage and premature aging but has a lower risk of developing skin cancer compared to fair-skinned individuals due to higher melanin levels. Option C) A 25-year-old dark-skinned male whose mother had skin cancer may have a genetic predisposition to skin cancer, but his dark skin provides natural protection against UV radiation, lowering his risk compared to fair-skinned individuals. Option D) A 70-year-old fair-skinned female who works as a secretary is at risk due to her fair skin, but her indoor job likely exposes her to less sun compared to an outdoor worker like the construction worker, reducing her risk compared to option B. In an educational context, understanding individual risk factors for skin cancer based on skin type, sun exposure, and genetic predisposition is crucial for healthcare providers to educate patients on preventive measures such as sun protection and regular skin screenings. This knowledge helps in personalized patient care and early detection of skin cancer.

Correct Answer: B

Rationale: The correct answer is B) Practice inhaling through the nose and exhaling slowly through pursed lips. This technique, known as pursed lip breathing, helps to slow down breathing, improve oxygen exchange, and reduce shortness of breath in patients with emphysema. It prevents small airways from collapsing, making breathing more efficient. Option A is incorrect because allowing additional time for physical activities does not directly address dyspnea management in emphysema. It may help reduce oxygen demand but does not teach the client a specific technique to manage dyspnea. Option C is incorrect as using a humidifier may be beneficial for some respiratory conditions, but it is not the most effective strategy for managing dyspnea in emphysema. Emphysema is characterized by air trapping in the lungs, not necessarily related to air humidity. Option D is also incorrect because strengthening abdominal muscles through leg raises does not directly target dyspnea management in emphysema. While overall physical fitness is important, specific breathing techniques like pursed lip breathing are more effective for dyspnea control in emphysema. In an educational context, it's important for nurses to understand and teach evidence-based strategies for managing respiratory conditions like emphysema. Teaching patients effective breathing techniques empowers them to take control of their symptoms and improve their quality of life. Nurses play a crucial role in educating patients on self-management strategies to promote better health outcomes.