The nurse is planning to care for a client with a DX of COPD with a high anxiety level that causes SOB. Which action should the nurse take given the client's reaction to anxiety?

Correct Answer: B

Rationale: The correct answer is B) Teach pursed lip breathing to use when feeling anxious. This is the most appropriate action because pursed lip breathing helps COPD patients manage their shortness of breath by slowing down their breathing rate, promoting better oxygen exchange, and reducing anxiety levels. Teaching this technique empowers the client to actively participate in managing their symptoms. Option A) Administering anti-anxiety medication PRN may provide temporary relief but does not address the underlying issue of anxiety. It is important to teach coping strategies that clients can use independently. Option C) Discouraging visitors who may cause anxiety does not address the client's ability to manage anxiety when they are alone or in other triggering situations. It is essential to equip the client with skills to cope in various circumstances. Option D) Teaching the proper use of inhalers is important for managing COPD symptoms but does not directly address the client's anxiety level. Separating the management of COPD symptoms from anxiety management is crucial for comprehensive care. In an educational context, teaching clients coping strategies like pursed lip breathing empowers them to take an active role in managing their condition. By providing practical tools to address anxiety, nurses can improve the client's quality of life and promote self-care and independence in managing their COPD.

Correct Answer: C

Rationale: In this scenario, the nurse's priority action should be option C: assess the client's respiratory status and oxygen saturation. This is the correct answer because when a client with emphysema on oxygen therapy reports increasing shortness of breath, it is crucial to first assess their current respiratory status and oxygen saturation levels. These assessments provide immediate information about the client's oxygenation status and help the nurse determine the appropriate next steps in care. Option A, increasing the oxygen flow rate to 4 L/min, is not the priority action because changing the oxygen flow without assessing the client's status can be potentially harmful. It is important to gather data before making any adjustments to the oxygen therapy. Option B, notifying the healthcare provider immediately, is also not the priority at this moment. While it is essential to involve the healthcare provider in the client's care, assessing the client's condition should come first to provide timely and appropriate interventions. Option D, positioning the client in high Fowler's position, may help improve ventilation but does not address the immediate need to assess the client's respiratory status and oxygen saturation levels. In an educational context, this question highlights the significance of prioritizing assessments in nursing care. It reinforces the importance of data collection and critical thinking in making clinical decisions. Understanding the rationale behind prioritizing actions based on assessment findings is crucial for safe and effective nursing practice, especially in situations where prompt interventions are necessary to ensure patient safety and well-being.

Correct Answer: B

Rationale: In the context of a client with COPD being prescribed tiotropium (Spiriva), option B, "This medication is used for long-term management, not quick relief," is the correct answer. This is because tiotropium is a long-acting bronchodilator that helps to manage COPD symptoms over time by improving lung function and reducing exacerbations. It is not meant for immediate relief of symptoms during exacerbations, as stated in option A. Option C, "Avoid eating grapefruit while taking this medication," is incorrect as there is no known interaction between tiotropium and grapefruit. Option D, "Take the medication with food to prevent stomach upset," is also incorrect as tiotropium is typically taken on an empty stomach. In an educational context, it is crucial for nurses to understand the rationale behind medication administration to provide effective patient education. By emphasizing that tiotropium is a long-term management medication, nurses can ensure that patients use it correctly to achieve optimal therapeutic outcomes in the management of COPD. This knowledge helps in promoting patient adherence and self-management in the long-term care of COPD.

Correct Answer: B

Rationale: The correct answer is B) Prepare the client for a thoracentesis. In the context of a client with pleural effusion experiencing severe shortness of breath, a thoracentesis is the priority intervention to remove the accumulated fluid from the pleural space, relieving pressure on the lungs and improving oxygenation. This procedure can rapidly improve the client's breathing and oxygen levels, addressing the immediate respiratory distress. Option A) Position the client on the unaffected side may provide some comfort but does not address the underlying cause of the shortness of breath, which is the pleural effusion compromising lung expansion. Option C) Administer prescribed diuretics may be part of the treatment plan for managing pleural effusion in the long term by reducing fluid retention, but it is not the immediate priority in a client experiencing severe respiratory distress. Option D) Encouraging deep breathing exercises is not appropriate when the client is in severe respiratory distress due to pleural effusion. The priority is to relieve the pressure on the lungs through thoracentesis before focusing on breathing exercises. In an educational context, understanding the priority interventions for clients with respiratory conditions like pleural effusion is crucial for nurses to provide timely and effective care, especially in acute situations where respiratory compromise can quickly escalate. This question highlights the importance of critical thinking and prioritization in nursing practice, emphasizing the significance of addressing the root cause of respiratory distress to ensure optimal patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) Rinse your mouth after each use. This teaching point is crucial for a client using a corticosteroid inhaler for COPD to prevent the development of oral thrush, a common side effect of inhaled corticosteroids. Rinsing the mouth helps to remove any medication residue that could lead to fungal overgrowth in the mouth. Option A) Use the inhaler only when symptoms worsen is incorrect because corticosteroid inhalers are typically used on a regular schedule to manage inflammation and prevent symptoms from worsening. Option C) Shake the inhaler only if symptoms persist is incorrect because corticosteroid inhalers need to be shaken before each use to ensure proper dispersion of the medication for effective delivery to the lungs. Option D) Use the inhaler before a bronchodilator is incorrect because bronchodilators are usually used first to help open the airways, followed by corticosteroid inhalers to reduce inflammation. In an educational context, it is essential for nurses to provide clear and accurate instructions on the use of inhalers to promote optimal therapeutic outcomes and prevent adverse effects. Teaching patients about proper inhaler technique and potential side effects empowers them to effectively manage their condition and improve their quality of life.