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1. A nurse is conducting a home visit for a client with chronic
obstructive pulmonary disease (COPD). The nurse observes that the
client has difficulty breathing, cyanosis of the lips and nail beds, and
a productive cough with yellowish sputum. The nurse also notices
that the client's home is poorly ventilated and has a strong smell of
cigarette smoke. What is the most appropriate action for the nurse
to take in this situation?
a) Advise the client to quit smoking and refer them to a smoking
cessation program.
b) Administer oxygen therapy and monitor the client's vital signs.
c) Educate the client about the signs and symptoms of COPD
exacerbation and when to seek medical help.
d) *Assess the client's oxygen saturation level and respiratory status,
and contact the primary care provider for further instructions.*
Rationale: The correct answer is d. The nurse should first assess the
client's oxygen saturation level and respiratory status, as these are
indicators of hypoxemia and respiratory distress, which are lifethreatening conditions. The nurse should then contact the primary
care provider for further instructions, as the client may need
medication adjustment or hospitalization. The other options are not
as urgent or appropriate as option d, although they may be part of
the long-term management plan for the client.
2. A nurse is working in a community health center that provides
services for low-income and uninsured populations. The nurse is
assigned to conduct a health promotion workshop for a group of
women who are at risk for cervical cancer. The nurse plans to use the
Health Belief Model (HBM) as a framework for the workshop.Â
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