What is the most effective action when a client presents with acute shortness of breath and a history of COPD?

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. In acute shortness of breath with COPD, oxygen therapy is crucial to improve oxygenation levels and alleviate respiratory distress. Oxygen can help reduce the workload on the lungs and heart. Antibiotics (B) are not indicated unless there is a suspected bacterial infection. Monitoring blood glucose (C) is important in diabetes management but not the priority in acute respiratory distress. Administering pain relief (D) may not address the underlying cause of the shortness of breath. Oxygen therapy directly targets the respiratory issue in COPD exacerbation, making it the most effective initial intervention.

Correct Answer: D

Rationale: Correct Answer: D - Administering oxygen Rationale: 1. Oxygen is crucial in acute myocardial infarction to improve oxygenation and reduce myocardial workload. 2. Administering oxygen helps alleviate ischemia and prevents further damage. 3. Prioritizing oxygenation before pain medication or assessment ensures immediate intervention for the patient's well-being. Summary of other choices: A: Administering pain medication - Important for comfort but not the priority in acute myocardial infarction. B: Performing a head-to-toe assessment - Necessary but not as urgent as ensuring oxygenation. C: Establishing an intravenous line - Helpful but not as critical as administering oxygen in this scenario.

Correct Answer: C

Rationale: The correct immediate intervention for a hypoglycemic client is to provide 4-6 ounces of fruit juice with sugar. This is because the client needs a quick source of glucose to raise their blood sugar levels rapidly. Fruit juice with sugar is easily absorbed, providing a fast-acting solution to hypoglycemia. Commercially prepared glucose tablets may take longer to be absorbed than fruit juice. Hard candies and honey may not contain enough sugar to raise blood sugar levels quickly compared to fruit juice. Therefore, fruit juice with sugar is the most effective option for immediate intervention in hypoglycemic clients.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to relax and open up the airways, which can alleviate shortness of breath and chest tightness in conditions like asthma or COPD. Administering oxygen (choice B) can help if the client is hypoxic, but it does not directly address the underlying airway constriction. Applying a cold compress (choice C) may provide some comfort but will not address the respiratory distress. Administering IV antibiotics (choice D) is not indicated for shortness of breath and chest tightness unless there is an underlying bacterial infection.

Correct Answer: D

Rationale: The correct answer is D: Administer nitroglycerin. In acute pancreatitis, pancreatic inflammation can lead to pancreatic ischemia due to decreased blood flow. Nitroglycerin helps to dilate blood vessels and improve blood flow to the pancreas, reducing ischemia and potentially preventing further damage. Pain relief (choice A) may be necessary but does not address the underlying issue of ischemia. Administering fluids (choices B and C) is important but not the most critical intervention in this case. Administering nitroglycerin is the most crucial because it targets the root cause of pancreatic ischemia in acute pancreatitis.

Correct Answer: C

Rationale: The correct answer is C: Placing the client on their back. This is the priority because it helps optimize the client's breathing mechanics by maximizing lung expansion. By positioning the client on their back, it allows for better oxygenation and ventilation. Administering oxygen (A) and albuterol (B) can be important interventions but positioning comes first. Placing the client on their back also helps prevent aspiration and facilitates airway clearance. Encouraging deep breathing (D) is beneficial, but if the client is in respiratory distress, ensuring proper positioning takes precedence over deep breathing exercises.

Correct Answer: C

Rationale: The correct answer is C: Swelling in the legs and shortness of breath. In heart failure, the heart is unable to pump effectively, leading to fluid accumulation in the body. Swelling in the legs (edema) is a classic sign of fluid overload as the fluid pools in the lower extremities. Shortness of breath occurs due to fluid accumulating in the lungs, causing difficulty in breathing. Weight loss and increased appetite (A) are not typical signs of fluid overload. Increased urine output and dehydration (B) are more indicative of fluid deficit. Nausea and vomiting (D) can occur in various conditions but are not specific to fluid overload in heart failure.

Correct Answer: D

Rationale: The correct answer is D because it describes the setting of the symptoms by specifying when the pain occurs (every time the patient sits down to use the computer). This detail helps identify possible triggers or patterns associated with the pain. Choices A, B, and C focus on the nature or characteristics of the pain rather than the setting, making them incorrect. Choice A describes the type of pain, choice B includes associated symptoms, and choice C reflects the patient's interpretation of the pain, none of which directly address the setting of the symptoms.

Correct Answer: A

Rationale: The correct answer is A because it helps differentiate between orthopnea (difficulty breathing when lying down) and paroxysmal nocturnal dyspnea (sudden awakening due to difficulty breathing). By asking about worsening symptoms when lying down, the nurse can assess if the patient has orthopnea, a classic symptom of heart failure. Choices B, C, and D are incorrect because they do not specifically target the nighttime breathing difficulty associated with heart failure.