1. A 65-year-old male patient with a history of chronic obstructive

pulmonary disease (COPD) and hypertension presents to the clinic with

dyspnea, wheezes, and productive cough. He reports that he has been

using his albuterol inhaler more frequently in the past week. His vital

signs are: blood pressure 160/90 mmHg, pulse 100 beats/min, respiratory

rate 24 breaths/min, oxygen saturation 92% on room air. What is the most

appropriate initial action by the nurse practitioner?

a) Prescribe a short course of oral corticosteroids

b) Order a chest x-ray and sputum culture

c) Refer the patient to a pulmonologist

d) *Increase the dose of his antihypertensive medication*

Rationale: The patient is experiencing an acute exacerbation of COPD,

which is a common cause of dyspnea, wheezes, and productive cough in

this population. The most appropriate initial action by the nurse

practitioner is to increase the dose of his antihypertensive medication, as

hypertension is a risk factor for worsening COPD and can lead to

pulmonary edema, heart failure, and arrhythmias. Oral corticosteroids may

be indicated for severe exacerbations, but they have significant side

effects and should not be used as first-line therapy. A chest x-ray and

sputum culture may be helpful to rule out pneumonia or other infections,

but they are not urgent and do not address the underlying cause of the

exacerbation. Referring the patient to a pulmonologist may be appropriate

for long-term management, but it does not provide immediate relief for the

patient's symptoms.

2. A 70-year-old female patient with a history of type 2 diabetes mellitus

and peripheral neuropathy presents to the clinic with a non-healing ulcer

on her left foot. She reports that she noticed the ulcer about two weeks ago

after wearing a new pair of shoes. She has been applying antibiotic

ointment and changing the dressing daily, but the ulcer has not improved.

On examination, the ulcer is 2 cm in diameter, with yellowish exudate and

surrounding erythema. There is no palpable pulse in the left dorsalis pedis

artery. The patient's blood glucose level is 250 mg/dL. What is the most

appropriate intervention by the nurse practitioner?

a) *Refer the patient to a vascular surgeon*

b) Prescribe oral antibiotics and debride the ulcer

c) Order an ankle-brachial index (ABI) and Doppler ultrasound