Which patient statement indicates the need for further teaching about pursed-lip breathing?

Correct Answer: D

Rationale: The correct answer is D because puffing the cheeks while exhaling through pursed lips is not a correct technique for pursed-lip breathing. Pursed-lip breathing involves inhaling through the nose and exhaling slowly through pursed lips, which helps improve breathing efficiency. Option A correctly describes the inhalation and exhalation process. Option B correctly mentions the recommended exhalation duration. Option C correctly suggests practicing pursed-lip breathing during activities.

Correct Answer: A

Rationale: The correct first action is to assess the patient's oxygen saturation (Choice A). Confusion in a patient with pneumonia could indicate hypoxemia, so assessing oxygen saturation helps determine if the confusion is due to inadequate oxygen supply. This step is crucial for immediate intervention. Notifying the healthcare provider (Choice B) can be important but should come after assessing the patient's oxygen saturation. Administering antibiotics (Choice C) is necessary but should not be the first action when a change in mental status occurs. Reassessing vital signs (Choice D) is important but may not provide immediate information on the cause of confusion.

Correct Answer: C

Rationale: The correct answer is C: Arrange for the patient's friend to administer the medication on schedule. This intervention addresses the patient's social support system, ensuring someone close to them can help with medication adherence. Homelessness and alcohol abuse can make it challenging for the patient to adhere to the treatment regimen independently. Providing support from a trusted friend can increase accountability and motivation. A: Repeating warnings may not address the underlying issues of homelessness and alcohol abuse. B: Giving written instructions may not be effective if the patient struggles with literacy or forgetfulness. D: While providing meals and drug administration at a community center may be helpful, it doesn't address the patient's need for personalized support.

Correct Answer: A

Rationale: The correct answer is A: Administer a laxative. Administering a laxative is the first step before a colonoscopy to ensure the colon is clear for better visualization. High fiber intake (B) may be recommended after the procedure. Stool softeners (C) are used for constipation but not typically prior to a colonoscopy. Encouraging ambulation (D) is beneficial post-procedure but not the first step.

Correct Answer: A

Rationale: The correct answer is A: Administer warming measures. The priority nursing action for a patient experiencing hypothermia is to prevent further heat loss and actively rewarm the patient to restore normal body temperature. This is crucial to prevent complications such as cardiac arrhythmias and impaired immune function. Administering warming measures, such as using warming blankets, heating pads, warm IV fluids, and adjusting room temperature, helps to increase the patient's core body temperature. Administering oxygen therapy (B) may be necessary for other conditions but is not the priority in this scenario. Repositioning the patient (C) may help with comfort and circulation but does not address the underlying issue of hypothermia. Administering antipyretics (D) is used to reduce fever, not hypothermia, and would not be effective in this case.