A client with pneumonia has a productive cough and fever. Which intervention should the nurse prioritize?

Correct Answer: D

Rationale: In this scenario, the correct answer is option D: Collecting a sputum culture. The priority for a client with pneumonia exhibiting a productive cough and fever is to identify the causative organism through a sputum culture. This will guide appropriate antibiotic therapy, crucial for effective treatment of pneumonia. Option A (Encouraging fluid intake) is important for maintaining hydration but is not the priority when the client's condition requires immediate intervention for diagnosis and treatment. Option B (Administering antipyretics) addresses the fever symptomatically but does not address the underlying cause. Option C (Performing chest physiotherapy) may be beneficial in mobilizing secretions but is not the priority over identifying the infectious agent causing the pneumonia. Educationally, this question highlights the importance of critical thinking in prioritizing interventions based on the client's condition and the urgency of the situation. It emphasizes the significance of diagnostic procedures in guiding appropriate treatment and the role of nurses in clinical decision-making to ensure optimal patient outcomes.

Correct Answer: A

Rationale: In the context of a client with a tracheostomy at risk for aspiration, the nurse should prioritize providing thickened liquids with meals (Option A) as the correct intervention. Thickened liquids are recommended to reduce the risk of aspiration in individuals with swallowing difficulties or tracheostomies. Thickened liquids move more slowly, making them easier to control and swallow, decreasing the risk of liquid entering the airway. Suctioning the tracheostomy before meals (Option B) can help maintain airway patency but does not directly address the risk of aspiration during meals. Positioning the client flat during feeding (Option C) can increase the risk of aspiration as it promotes reflux and pooling of liquids in the throat. Encouraging the client to drink water with meals (Option D) can increase the risk of aspiration due to the thin consistency of water. In an educational context, it is crucial for nurses to understand the principles of safe feeding practices for clients with tracheostomies to prevent complications like aspiration pneumonia. By prioritizing the provision of thickened liquids, nurses can ensure the safety and well-being of clients with these specific care needs.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B) Respiratory rate of 8 breaths/minute. Emphysema is a condition characterized by damaged air sacs in the lungs, leading to poor oxygen exchange. A low respiratory rate (bradypnea) can indicate respiratory depression or impending respiratory failure in patients with emphysema. This finding is concerning as it may suggest hypoventilation and inadequate oxygenation despite oxygen therapy. Option A) Fine bibasilar crackles may be expected in patients with emphysema due to underlying lung damage and secretions, but they do not indicate an immediate concern related to oxygen therapy. Option C) The patient sitting up and leaning over the nightstand is a position often assumed by patients with respiratory distress to facilitate breathing and is not an immediate concern. Option D) A large barrel chest is a typical physical characteristic of emphysema and does not raise immediate concern regarding oxygen therapy. Educationally, understanding the rationale behind monitoring respiratory rate in patients receiving oxygen therapy is crucial for nurses caring for patients with respiratory conditions. Recognizing abnormal signs and symptoms promptly can help prevent complications and improve patient outcomes.

Correct Answer: D

Rationale: In this multiple-choice question on oxygen therapy, option D, "I will elevate my head for 48 hours to minimize swelling," is the correct answer. This statement indicates successful teaching because elevation of the head post-rhinoplasty helps reduce swelling by promoting better drainage of fluids. It is a crucial instruction for post-operative care in rhinoplasty to enhance healing and optimize outcomes. Option A, "My nose will look normal after 24 to 48 hours," is incorrect as the immediate post-operative appearance after rhinoplasty includes swelling and bruising, and it takes time for the nose to heal and for swelling to subside. Option B, "I can take 800 mg ibuprofen every 6 hours for pain," is incorrect because ibuprofen can increase the risk of bleeding post-operatively, and alternative pain management strategies are usually recommended after rhinoplasty. Option C, "I will remove and reapply the nasal packing every day," is incorrect as nasal packing is typically removed by healthcare providers during a follow-up visit and should not be manipulated by the patient at home to prevent complications. In an educational context, it's essential for nurses to provide accurate and clear discharge instructions to patients undergoing rhinoplasty to ensure optimal recovery and outcomes. Teaching patients about proper post-operative care, including instructions like head elevation, can help prevent complications and promote successful healing.

Correct Answer: D

Rationale: In this scenario, the most concerning finding among the options provided is option D) The patient's heart rate is 120 beats per minute. This is because an elevated heart rate post-thoracic surgery can be indicative of various complications such as hemorrhage, hypoxia, or cardiac issues, necessitating immediate attention and further assessment. Option A) The patient has 150 mL of bloody drainage in the first hour is a common finding post-thoracic surgery and would require monitoring but is not as acutely concerning as an elevated heart rate. Option B) The patient reports pain at the surgical site is also common postoperatively and can be managed with appropriate pain relief measures, making it a less concerning finding compared to the elevated heart rate. Option C) The patient's chest tube is bubbling intermittently can be a normal finding related to the functioning of the chest tube drainage system and does not necessarily indicate a critical issue requiring immediate intervention. Educationally, understanding the significance of vital sign changes postoperatively is crucial for nurses caring for patients after thoracic surgery. Recognizing abnormal vital sign patterns and prioritizing interventions based on these findings can help prevent complications and improve patient outcomes.