The nurse is planning to care for a client with COPD who has a high anxiety level that causes shortness of breath. 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 intervention helps the client manage anxiety-induced shortness of breath by promoting relaxation and improving oxygen exchange. Pursed-lip breathing slows down the client's breathing rate, reduces respiratory rate, and decreases the work of breathing. It also helps to prevent air trapping in the lungs. Administering anti-anxiety medication (Option A) should not be the first-line intervention for managing anxiety-induced shortness of breath. Discouraging visitors (Option C) may isolate the client and not address the underlying issue of anxiety. Teaching proper use of inhalers (Option D) is important for managing COPD symptoms, but it does not directly address anxiety-related shortness of breath.

Correct Answer: C

Rationale: The correct answer is C because the high-pressure alarm on the ventilator sounding indicates that the patient is experiencing increased airway pressure, which can lead to barotrauma and compromise ventilation. Immediate intervention is required to prevent lung injury. Choice A (respiratory rate of 22 breaths/min) is within the normal range and does not indicate an urgent need for intervention. Choice B (arterial oxygen saturation of 89%) is low but may not require immediate intervention as long as it is not rapidly declining and other factors are stable. Choice D (patient attempting to remove the endotracheal tube) is concerning but may not require immediate intervention as long as the airway is still secured, and other parameters are stable.

Correct Answer: B

Rationale: The correct answer is B because changing the tracheostomy ties before cleaning the stoma can lead to contamination of the stoma site. The correct sequence should be to first clean the stoma with saline solution, then change the tracheostomy ties, and finally apply a new sterile dressing. This helps prevent infection and ensures proper hygiene. Choices A, C, and D are incorrect because using sterile technique for suctioning, applying a new sterile dressing, and cleaning the stoma with saline solution are all appropriate actions in tracheostomy care.

Correct Answer: D

Rationale: The correct answer is D: Ensuring the patient is sitting upright during the treatment. This is important because being in an upright position optimizes lung expansion and airflow, promoting better drug delivery to the lungs. Sitting upright also helps prevent potential aspiration of the medication. Choice A is incorrect because the breathing technique (in through nose, out through mouth) is not the most critical aspect of nebulizer administration. Choice B is incorrect because while monitoring for tachycardia is important, it is not the most crucial action during bronchodilator administration. Choice C is incorrect because diluting the medication with normal saline may be necessary for certain medications, but it is not the most important action when administering a bronchodilator via nebulizer.

Correct Answer: A

Rationale: The correct action is to assess for diminished lung sounds first. Pleuritic chest pain and fever can indicate a potential respiratory issue like pneumonia. Assessing lung sounds can provide immediate information on the patient's respiratory status and guide further interventions. Administering antipyretics can help manage the fever but does not address the underlying cause. Obtaining a sputum sample for culture is important for identifying the specific pathogen causing the infection but is not the first priority. Placing the patient in a high Fowler's position can improve oxygenation but should come after assessing lung sounds to ensure appropriate positioning.