The nurse observes a patient with COPD practicing pursed-lip breathing. What does this indicate?

Correct Answer: A

Rationale: The correct answer is A because pursed-lip breathing is a technique commonly used by patients with COPD to improve breathing efficiency by slowing down exhalation and keeping airways open. This helps to reduce air trapping and improve oxygen exchange. Option B is incorrect because pursed-lip breathing is not primarily used for anxiety reduction. Option C is incorrect as it doesn't directly relate to pursed-lip breathing. Option D is incorrect because pursed-lip breathing is a preventive technique rather than a response to acute shortness of breath.

Correct Answer: C

Rationale: The correct answer is C: Monitor the patient's respiratory rate. This is the priority nursing intervention because anticoagulant therapy can lead to potential bleeding complications, such as pulmonary embolism. Monitoring the patient's respiratory rate helps assess for signs of bleeding or clot formation in the lungs, which are critical to address promptly. A: Monitoring INR levels is important but not the priority over assessing for immediate complications. B: Increasing fluid intake may be beneficial for some conditions but is not the priority in this case. D: Administering an antifungal medication is unrelated to anticoagulant therapy and not a priority intervention.

Correct Answer: A

Rationale: The correct answer is A: Administer a bronchodilator. This is the priority intervention because wheezing indicates airway constriction in asthma, requiring immediate relief to improve breathing. Bronchodilators help dilate the airways, providing quick relief. Administering an inhaled corticosteroid (B) is important for long-term control, not immediate relief. Administering an IV analgesic (C) is not necessary for wheezing in asthma. Performing a neurological assessment (D) is not relevant and does not address the immediate respiratory issue.

Correct Answer: B

Rationale: The correct answer is B: Encourage the patient to sit up at the bedside in a chair and lean forward. This position, known as the orthopneic position, helps improve ventilation in COPD patients by reducing the pressure on the diaphragm and allowing for better expansion of the lungs. By sitting up and leaning forward, the patient can maximize their lung capacity and facilitate better gas exchange. A: Having the patient rest in bed with the head elevated to 15 to 20 degrees may help with breathing comfort but does not provide the same level of lung expansion as the orthopneic position. C: Resting in bed in a high-Fowler's position with the knees flexed may help with respiratory effort but does not promote optimal ventilation like sitting up in a chair and leaning forward. D: This is a duplicate of option C. In summary, option B is the best choice as it directly supports improved ventilation and gas exchange in COPD patients compared to the other options.

Correct Answer: B

Rationale: The correct answer is B: Administer a corticosteroid. The priority intervention is to address the potential cause of the severe headache, which could be due to increased intracranial pressure (ICP) resulting from the stroke. Corticosteroids, such as dexamethasone, are often used to reduce brain edema and inflammation in stroke patients. Administering analgesics (choice A) may provide temporary relief but does not address the underlying issue. Assessing respiratory status (choice C) is important but not the priority in this case. Administering beta-agonists (choice D) is not indicated for managing a severe headache in a stroke patient.