A nurse is caring for a patient with a history of stroke. The patient is exhibiting facial drooping. What is the priority action?

Correct Answer: A

Rationale: The correct answer is A: Administer aspirin. Aspirin is indicated as a priority action for a patient exhibiting facial drooping, as it may suggest the patient is experiencing a potential stroke. Aspirin helps prevent blood clot formation, which is crucial in ischemic strokes. Immediate administration of aspirin can help reduce the risk of further clot formation and minimize potential brain damage. Administering nitroglycerin (choice B) is not appropriate for stroke management. Short-acting bronchodilators (choice C) are not relevant to the patient's presentation. Administering antibiotics (choice D) is not indicated unless there is a specific infection present.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Suction the tracheostomy when directed. This task falls within the scope of practice for an experienced LPN/LVN. Suctioning a tracheostomy requires skill and precision to maintain airway patency and prevent complications such as mucus plugging or respiratory distress. LPNs/LVNs are trained to perform this procedure safely under the guidance and direction of an RN or physician. Option A, assessing the patient's risk for aspiration, involves critical thinking skills and complex decision-making that are typically within the RN's scope of practice. Delegating this task to an LPN/LVN may not be appropriate as it requires a higher level of clinical judgment. Option C, teaching the patient tracheostomy self-care, involves patient education and empowerment, which are often responsibilities of the RN who can provide comprehensive education and assess the patient's understanding and ability to perform self-care effectively. Option D, determining the need for tracheostomy tube replacement, is a decision that requires advanced assessment skills and clinical knowledge that are typically within the RN's scope of practice. This task involves evaluating the patient's condition, assessing the tracheostomy site, and making critical decisions regarding tube changes based on patient-specific factors. In an educational context, it is essential for healthcare professionals to understand their scope of practice and responsibilities when delegating tasks to ensure safe and effective patient care. By correctly assigning tasks based on individual competencies and regulations, the healthcare team can work collaboratively to provide optimal care for patients with complex needs, such as those with permanent tracheostomies.

Correct Answer: A

Rationale: The correct answer to the question is option A) Resources for support in smoking cessation. This is the most appropriate information to include for a patient with a 42 pack-year history of cigarette smoking because smoking cessation is the single most effective way to prevent further lung damage and reduce the risk of developing lung diseases such as chronic obstructive pulmonary disease (COPD) and lung cancer. Option B) Reasons for annual sputum cytology testing is incorrect because while sputum cytology testing may be part of lung cancer screening protocols for high-risk individuals, it is not the most crucial information to provide to a patient with a significant smoking history. Option C) Erlotinib (Tarceva) therapy to prevent tumor risk is also incorrect as this medication is typically used in the treatment of non-small cell lung cancer and is not indicated for primary prevention in a patient with a smoking history. Option D) Computed tomography (CT) screening for cancer is not the most appropriate information to provide as the initial focus should be on smoking cessation rather than solely on cancer screening. In an educational context, it is important for nurses to understand the critical role of smoking cessation in preventing lung disease and to prioritize providing support and resources to patients with a history of smoking. By emphasizing the benefits of quitting smoking and connecting patients with appropriate cessation programs, nurses can significantly impact the health outcomes of individuals at risk for lung diseases related to smoking.

Correct Answer: C

Rationale: In this scenario, the most immediate action by the nurse is to address the disconnected epoprostenol infusion (Option C). Epoprostenol is a pulmonary vasodilator crucial for managing pulmonary arterial hypertension. Its sudden discontinuation can lead to a rapid increase in pulmonary artery pressure, potentially causing life-threatening complications for the patient. Reconnecting the infusion promptly is essential to prevent a severe deterioration in the patient's condition. Option A (O₂ saturation is 90%) is not the most immediate concern in this case. While a saturation of 90% may indicate hypoxemia and require monitoring and intervention, the immediate risk posed by a disconnected epoprostenol infusion takes precedence. Option B (blood pressure is 98/56 mm Hg) is within a range that may be acceptable for a patient with IPAH. While monitoring blood pressure is important in these patients, it is not the most critical issue compared to a disconnected epoprostenol infusion. Option D (prolonged INR) is not directly related to the immediate management of a patient with IPAH and a disconnected epoprostenol infusion. While an elevated INR may indicate a risk of bleeding, it is not as urgent as addressing the potential consequences of interrupting a crucial medication like epoprostenol in a patient with IPAH. In an educational context, understanding the priority of interventions in caring for patients with specific conditions is vital for nurses. This scenario highlights the importance of recognizing critical situations, prioritizing care based on patient needs, and taking prompt action to ensure patient safety and well-being in acute care settings.

Correct Answer: B

Rationale: The correct answer, option B, is the most useful in evaluating the effectiveness of treatment for impaired gas exchange. Pulse oximetry directly measures the oxygen saturation in the blood, providing a real-time assessment of how well oxygen is being transported in the body. This objective measurement gives a clear indication of the patient's gas exchange status and the effectiveness of interventions aimed at improving oxygenation. Option A, even unlabored respirations, is a subjective assessment that may not accurately reflect the patient's actual oxygenation status. Patients can sometimes compensate for impaired gas exchange by altering their breathing patterns, making this finding less reliable for evaluating treatment efficacy. Option C, absence of wheezes or crackles, is important for assessing lung sounds and respiratory function but does not provide a direct measure of oxygenation. Improvements in lung sounds do not always correlate with improved gas exchange. Option D, a respiratory rate of 18 breaths/min, is a vital sign that can indicate respiratory distress but does not provide specific information on oxygenation levels. Changes in respiratory rate may be influenced by factors other than oxygenation, making it less specific for evaluating the effectiveness of treatments targeting gas exchange. In an educational context, understanding the importance of using objective measures like pulse oximetry to assess gas exchange is crucial for nurses caring for patients with respiratory conditions. It emphasizes the need for evidence-based practice and accurate monitoring to guide interventions and evaluate patient outcomes effectively. Nurses should be able to interpret various assessment findings and prioritize those that directly reflect the desired treatment goals to deliver high-quality, patient-centered care.