A nurse is caring for a patient with a history of asthma. The patient is experiencing difficulty breathing. What is the priority intervention?

Correct Answer: A

Rationale: The correct answer is A: Administer a bronchodilator. This is the priority intervention because the patient is experiencing difficulty breathing, indicating an asthma exacerbation. Administering a bronchodilator helps to open up the airways and improve breathing. It targets the underlying cause of the respiratory distress. Administering IV fluids (choices B and C) may be necessary for hydration but is not the priority in this situation. Administering pain relief (choice D) is not appropriate as the priority is addressing the breathing difficulty.

Correct Answer: A

Rationale: In this scenario, option A is the correct answer because an oxygen saturation level of 89% indicates hypoxemia, which is a critical condition requiring immediate intervention to optimize oxygenation and prevent further complications such as tissue damage, organ dysfunction, or even cardiac arrest. As the nurse's priority is to ensure adequate oxygenation for the patient's well-being, addressing hypoxemia takes precedence over other assessment findings. Options B, C, and D are incorrect in this context. Option B, the red and swollen nose, is a common and expected finding in a patient with nasal packing after a nosebleed and does not pose an immediate threat to the patient's health. Option C, the patient's pain level, while important for overall patient care, does not take precedence over the critical issue of hypoxemia. Option D, a temperature of 100.1°F, may indicate a mild fever but is not as urgent as addressing hypoxemia. Educationally, this question highlights the importance of prioritizing patient assessments based on the severity of the condition. It emphasizes the need for nurses to quickly recognize and address life-threatening situations such as hypoxemia to ensure patient safety and well-being. Understanding the significance of oxygen saturation levels and their impact on overall patient health is crucial for nurses in various clinical settings.

Correct Answer: C

Rationale: The most appropriate response by the nurse in this scenario is option C) Tell me what you know about the treatments available. This response is the most suitable because it allows the nurse to assess the patient's knowledge and understanding of the available treatment options for stage I non-small cell lung cancer. By understanding the patient's perspective and level of awareness, the nurse can address any misconceptions or fears the patient may have and provide tailored education and information to support the patient in making an informed decision about their treatment plan. Option A) Are you afraid that the surgery will be very painful? is not the best response because it assumes the patient's choice is based solely on fear of pain, overlooking other important factors that may influence their decision. Option B) Did you have bad experiences with previous surgeries? is not the most appropriate response as it assumes the patient's preference is based on past negative experiences with surgeries, which may not be the case for this particular patient. Option D) Surgery is the treatment of choice for stage I lung cancer is not the ideal response as it dismisses the patient's concerns and preferences, failing to engage in a meaningful conversation to address the patient's individual needs and decision-making process. In an educational context, it is crucial for healthcare providers to engage in open and empathetic communication with patients, especially when discussing treatment options for serious conditions like cancer. By actively listening to the patient's perspective and providing tailored information and support, healthcare professionals can empower patients to be active participants in their healthcare decisions and improve overall outcomes.

Correct Answer: A

Rationale: Rationale: The correct action for the nurse to take next is option A, which is to auscultate for breath sounds. This is the most appropriate initial step in assessing the patient's complaint of sharp pain upon deep breathing. Auscultating breath sounds can help the nurse identify any abnormal findings such as decreased or absent breath sounds that could indicate underlying issues like a pneumothorax or pleural effusion. By listening to the breath sounds, the nurse can gather crucial information to guide further assessment and management of the patient's condition. Option B, administering PRN morphine, is not the immediate priority in this scenario. While pain management is important, it is essential to first assess the underlying cause of the pain before administering analgesics. Option C, having the patient cough forcefully, may exacerbate the pain and is not indicated without a comprehensive assessment. Option D, notifying the patient's health care provider, can be considered after the initial assessment of breath sounds to report findings and collaborate on the patient's care plan. Educational Context: Understanding the importance of assessing breath sounds in a patient complaining of chest pain is crucial for nurses caring for patients with respiratory conditions like pneumonia. Auscultation is a fundamental nursing skill that helps in identifying respiratory abnormalities and guiding appropriate interventions. By prioritizing the assessment of breath sounds, nurses can promptly recognize potential complications and provide timely and effective care to improve patient outcomes. This case highlights the significance of systematic assessment and critical thinking in nursing practice to deliver safe and quality patient care.

Correct Answer: C

Rationale: In caring for a patient with cor pulmonale, monitoring for peripheral edema is crucial as it is a common expected finding due to fluid retention in right heart failure caused by lung disease. The correct answer, option C, is indicative of the pathophysiology of cor pulmonale, where the right side of the heart is unable to effectively pump blood to the lungs, leading to fluid accumulation in the body, particularly in the extremities. Option A, chest pain, is less likely in cor pulmonale unless there are complications like pulmonary embolism. Option B, finger clubbing, is associated with chronic hypoxia and conditions like cystic fibrosis, not specifically cor pulmonale. Option D, elevated temperature, is not a typical finding in cor pulmonale unless there is an underlying infection. In an educational context, understanding the signs and symptoms of cor pulmonale is vital for nurses caring for patients with respiratory conditions. Recognizing peripheral edema as a key indicator helps in early identification and appropriate management of this serious complication. This knowledge enhances nursing assessment skills and improves patient outcomes by facilitating timely interventions to address fluid overload in cor pulmonale.