A. Encourage client to drink water: While hydration is important for thinning secretions in COPD, encouraging fluid intake in a client experiencing acute respiratory distress may not be appropriate initially. The client’s dry mouth could be a result of mouth breathing due to hypoxia, but airway and breathing must be prioritized before addressing hydration.

B. Assist client to an upright position: Positioning the client upright (high Fowler’s) maximizes lung expansion and improves diaphragmatic movement, which facilitates better oxygenation. It is the most immediate and appropriate intervention to alleviate shortness of breath and anxiety caused by hypoxia. This intervention also helps reduce the work of breathing in COPD patients.

C. Apply a high-flow venturi mask: Although a Venturi mask delivers precise oxygen concentrations, high-flow oxygen can suppress the hypoxic drive in COPD clients. Oxygen should be titrated carefully in these clients, usually starting with low-flow oxygen and adjusted per blood gas results and should be guided by assessment, including pulse oximetry and arterial blood gas results.

D. Administer a prescribed sedative: Sedatives can suppress respiratory drive, particularly in older adults and those with chronic respiratory conditions like COPD. Although anxiety is present, addressing the underlying cause, hypoxia, should take priority. Sedatives should be used cautiously and only after stabilizing respiratory function.

A. Explain that weight loss will be reversed after the acute phase of the stroke has ended: This response minimizes the family’s concern and overlooks the current nutritional deficit. Waiting for the acute phase to pass without implementing strategies to support nutritional intake can result in malnutrition and delayed recovery.

B. Demonstrate the use of visual scanning during meals to the client and family: Visual perception deficits, such as unilateral neglect, are common after a CVA and may cause the client to ignore food on one side of the tray. Teaching visual scanning techniques helps the client become aware of the neglected side and promotes full food intake, directly addressing the nutritional concern.

C. Suggest that the family bring foods from home that the client enjoys eating: While bringing familiar foods may increase appetite, it does not address the underlying issue of impaired visual perception. Even with preferred foods, the client may still miss food on the affected side, leading to inadequate intake.

D. Encourage the family to offer to feed the client when she does not eat her entire meal: Feeding assistance should only be considered when the client is unable to feed herself. Promoting independence through visual scanning techniques enhances functional recovery and dignity, while dependency can hinder rehabilitation and motivation.

Myocardial Infarction (MI):

• Occurring without cause
• Feelings of fear
• Pain only relieved by opioids
• Epigastric distress
• Chest pain radiating down arm

Angina:

• Feelings of fear
• Pain relieved by nitroglycerin
• Chest pain radiating down arm

Rationale:

• Occurring without cause: MI pain often develops spontaneously without obvious exertional triggers. It may strike during rest or sleep due to complete blockage of a coronary artery, which differentiates it from angina that is typically exertion-induced.
• Feelings of fear: Both MI and angina can provoke intense feelings of fear or a sense of impending doom. The body's sympathetic response to chest pain and hypoxia can trigger anxiety and a heightened emotional reaction in both conditions.
• Pain relieved by nitroglycerin: Stable angina pain usually responds well to nitroglycerin because it reduces myocardial oxygen demand by dilating coronary vessels. Relief after nitroglycerin suggests the pain is related to transient ischemia rather than infarction.
• Pain only relieved by opioids: In MI, the ischemic injury is severe and prolonged, causing chest pain that is often refractory to nitroglycerin. Opioids like morphine are typically needed to manage the intense, persistent discomfort caused by myocardial tissue death.
• Epigastric distress: Epigastric pain or discomfort may occur especially with inferior wall MIs, mimicking indigestion or gastrointestinal upset. This atypical presentation can delay diagnosis, particularly in older adults and women.
• Chest pain radiating down arm: Radiation of chest pain to the left arm, jaw, neck, or back is common in both MI and angina. It occurs because the same spinal segments supply sensory nerves to the heart and these other areas, causing referred pain.

• Heart blocks: Heart blocks result from conduction abnormalities in the electrical pathways of the heart and are typically managed with pacemakers or medications, not directly corrected by PCI. PCI targets mechanical obstructions in the coronary arteries and does not primarily address conduction delays.
• Dysrhythmias: Restoring blood flow through PCI improves oxygen delivery to the myocardium, stabilizing the heart’s electrical activity. Ischemia often triggers dysrhythmias, and by relieving this ischemia, PCI reduces the risk of abnormal heart rhythms, particularly ventricular arrhythmias.
• Vasospasms: While vasospasms can cause transient coronary artery narrowing, they are usually managed with medications like calcium channel blockers. PCI is not typically used to treat vasospastic events unless they result in a fixed lesion or underlying atherosclerosis.
• Pain: Chest pain in this client is likely ischemic in nature due to reduced coronary perfusion. PCI relieves this ischemia by opening narrowed arteries, thereby reducing myocardial oxygen demand mismatch and leading to a significant reduction in chest pain symptoms.

• A. I will wear a medication alert bracelet to indicate my history of heart problems: This is an appropriate safety measure. Medical alert bracelets provide critical information in emergencies, ensuring first responders and healthcare providers are aware of the client’s cardiac history if he is unable to communicate.
• B. I will lie down or sit if I start to feel any chest discomfort: Sitting or lying down conserves energy and reduces myocardial oxygen demand during episodes of chest pain. This position also reduces fall risk if the client experiences hypotension after taking nitroglycerin.
• C. I will take the nitroglycerin 1 or 2 more times 10 minutes apart if pain does not get better: The correct guideline is to take nitroglycerin at 5-minute intervals, up to three doses total. Waiting 10 minutes between doses delays treatment and may worsen outcomes during acute coronary syndrome.
• D. I will call 911 if there is no improvement in my chest pain after taking nitroglycerin: This is correct. If chest pain persists after the first dose of nitroglycerin, emergency services should be contacted immediately to prevent delays in treating a possible myocardial infarction.
• E. I will chew my nitroglycerin tabs as soon as pain begins: Sublingual nitroglycerin tablets should not be chewed or swallowed, as this bypasses the intended absorption route under the tongue. Chewing reduces efficacy and delays relief during angina episodes.
• F. I will keep my nitroglycerin tablets with me all the time: Carrying nitroglycerin at all times is essential for clients with angina or cardiac risk. Immediate access allows for early treatment at the onset of symptoms, reducing the risk of progression to infarction.
• G. I will wait 5 minutes after taking my nitroglycerin to see if the pain improves: This statement aligns with current recommendations. Clients should assess for symptom relief within 5 minutes of taking the first dose before deciding to take additional doses or call emergency services.

A. Teach client to use pursed lip breathing when episodes occur: Pursed lip breathing can help improve ventilation and reduce air trapping during asthma exacerbations, but it is more of a supportive technique than a preventive one. It does not address the root cause of exercise-induced bronchoconstriction, which often requires pre-treatment strategies.

B. Review the client's routine asthma management prescriptions: While it's important to review long-term asthma management, exercise-induced bronchospasm requires pre-exercise interventions. The client may be compliant with their daily medications, but still experience exercise-induced asthma.

C. Assess client for signs and symptoms of upper airway infection: Respiratory infections can exacerbate asthma, but the client’s symptoms are specifically linked to exercise. Investigating an infection may be warranted if symptoms were persistent or unrelated to exertion, but it's not the most immediate or relevant action.

D. Determine if the client is using an inhaler before exercising: Short-acting beta-agonists (SABAs), such as albuterol, are commonly prescribed prophylactically for use prior to exercise to prevent exercise-induced bronchospasm. Confirming proper inhaler use before activity directly targets the client's concern and is a key step in asthma self-management.

A. Observe the color of the extremity: A thorough neurovascular assessment includes evaluating multiple components: pulses, color, temperature, capillary refill, sensation, and motor function. After confirming the pulse, assessing color helps determine perfusion and detect signs of ischemia or compromised circulation distal to the fracture.

B. Document the neurovascular assessment as normal: While the pulse is normal, the neurovascular assessment is incomplete without evaluating other parameters such as color, sensation, movement, and temperature. Documentation should only follow a full and thorough assessment.

C. Discontinue elevating the client's affected extremity: Elevation of a fractured extremity helps reduce swelling and promote venous return. There is no indication that elevation is harmful or unnecessary based on a normal pulse alone. This intervention should continue unless contraindicated.

D. Notify the healthcare provider of assessment finding: A present, regular, and full pulse is a normal finding and does not require immediate provider notification. The nurse should continue the assessment and only notify the provider if abnormal or concerning signs are detected, such as pallor, diminished sensation, or absent pulses.

A. Pulmonary function test: Pulmonary function tests assess chronic respiratory conditions such as asthma or COPD but are not appropriate during acute respiratory emergencies. In a trauma setting with absent breath sounds, these tests are irrelevant and would delay necessary life-saving interventions.

B. Endotracheal intubation: While intubation can support oxygenation in respiratory failure, it does not address the underlying issue if a pneumothorax or hemothorax is causing lung collapse. A chest tube is required first to re-expand the lung before or in conjunction with advanced airway support, if needed.

C. Chest tube insertion: Absent breath sounds on one side after trauma are strongly suggestive of a pneumothorax or hemothorax. A chest tube is urgently needed to evacuate air or blood from the pleural space and restore lung expansion, making this the most appropriate and immediate intervention.

D. Bronchoscopy: Bronchoscopy is used for visualizing the airway, retrieving foreign bodies, or assessing unexplained lung conditions. It is not a first-line emergency intervention for absent breath sounds following trauma and would not address the likely underlying cause such as a collapsed lung.

Calculation:

Total volume to be infused = 100 mL

Infusion time in hours:

Infusion time (hours) = Infusion time (minutes) / 60 minutes/hour

= 30 minutes / 60 minutes/hour

= 0.5 hours

Calculate the infusion rate in mL/hour:

Infusion rate (mL/hour) = Total volume (mL) / Infusion time (hours)

= 100 mL / 0.5 hours

= 200 mL/hour

• Deep vein thrombosis (DVT): The client presents with classic signs of DVT, including calf tenderness, unilateral edema and redness, increased calf circumference, low-grade fever, and a history of immobility following surgery—all of which increase thrombotic risk. A STAT Doppler and D-dimer were appropriately ordered, both of which help confirm or rule out DVT.
• Begin anticoagulation therapy: Anticoagulants like enoxaparin reduce clot propagation and the risk of pulmonary embolism, the most serious complication of DVT. This is a standard first-line treatment following a positive diagnosis or high clinical suspicion.
• Early ambulation: After stabilization and with provider clearance, early ambulation is encouraged to enhance venous return and prevent further thrombus formation. It must be done cautiously to avoid dislodging a clot if DVT is still untreated or unstable.
• Massage the calf area: This is contraindicated, as it may dislodge a clot and cause embolization to the lungs. It is strictly avoided in suspected or confirmed cases of DVT.
• Prep for return to surgery / Culture hip wound: These are not relevant to the current clinical concern. The surgical wound has minimal drainage, with no signs of infection or dehiscence.
• Development of pulmonary embolus: Clients with DVT are at high risk for PE. Monitoring for chest pain, shortness of breath, decreased oxygen saturation, and respiratory distress is essential for early detection and intervention.
• Laboratory values: Ongoing assessment of coagulation labs (PT, aPTT, platelet count) and renal function is critical to safely manage anticoagulation and ensure therapeutic response.
• Wound drainage / Nutritional intake / I&O: These are important for general postoperative care but are not specific to monitoring progress related to DVT or anticoagulation therapy.