A nurse is caring for a patient with a history of myocardial infarction (MI) who is experiencing shortness of breath. What is the priority action?

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy. The priority action is to address the patient's shortness of breath, which could indicate decreased oxygenation. Administering oxygen therapy helps improve oxygen levels and alleviate respiratory distress. IV fluids (B) are not indicated unless the patient is hypovolemic. Pain relief (C) is important but not the priority in this case. Administering thrombolytics (D) may be appropriate for an MI but is not the immediate priority when the patient is experiencing shortness of breath.

Correct Answer: A

Rationale: The correct answer is A: Administer bronchodilators. Bronchodilators help to open the airways quickly, providing immediate relief for the patient's shortness of breath in an acute asthma attack. This intervention addresses the patient's current distress and helps improve oxygenation. Administering corticosteroids (choice B) is important for long-term management but not the priority in an acute situation. Monitoring vital signs (choice C) is essential but not the immediate priority when the patient is in respiratory distress. Administering insulin (choice D) is not indicated for asthma and would not address the patient's shortness of breath.

Correct Answer: D

Rationale: The correct answer, D, is appropriate for delegation to unlicensed assistive personnel (UAP) because measuring induration at the site of an intradermal skin test is a task that is simple, non-invasive, and within the UAP scope of practice. It does not require specialized knowledge or interpretation, making it suitable for delegation. Option A, listening to a patient's lung sounds for wheezes or crackles, involves a higher level of skill and interpretation that should be done by a licensed healthcare provider. Option B, labeling specimens obtained during percutaneous lung biopsy, requires precision and accuracy to ensure proper specimen handling, which is beyond the scope of a UAP's responsibilities. Option C, instructing a patient about how to use home spirometry testing, involves patient education and requires a healthcare provider's expertise to ensure accurate instruction and understanding. In an educational context, understanding the delegation of tasks is crucial for providing safe and effective patient care. Nurses must be able to differentiate between tasks that can be delegated to UAPs and those that require the expertise of licensed healthcare providers. This knowledge ensures that patient care is delivered efficiently while maintaining quality and safety standards.

Correct Answer: C

Rationale: The correct option, C) Teach the patient to avoid nonsteroidal anti-inflammatory drugs (NSAIDs), is the most appropriate choice when teaching a patient about the use of expectorants. This is because NSAIDs can actually worsen respiratory conditions by causing bronchoconstriction and inhibiting the body's ability to clear secretions. It is crucial for patients using expectorants to be aware of this potential interaction to optimize their respiratory health. Option A) Use a swab to obtain a sample for a rapid strep antigen test, is incorrect as it is not related to teaching about expectorants. Rapid strep tests are used to diagnose streptococcal pharyngitis, which is unrelated to expectorant use. Option B) Discuss the need to rinse the mouth out after using any inhalers, while important for preventing oral thrush with inhaled corticosteroids, is not directly related to teaching about expectorants and their mechanisms of action in loosening mucus. In an educational context, understanding the rationale behind teaching patients about the appropriate use of expectorants is essential for healthcare providers. By providing accurate information and guidance on medication use, patients can better manage their respiratory conditions and improve their overall health outcomes. It is important to emphasize the specific instructions and precautions associated with expectorants to ensure patient safety and effectiveness of treatment.

Correct Answer: B

Rationale: The correct answer is to continue to monitor the collection device (Option B) because continuous bubbling in the suction-control chamber of a chest tube collection device is expected when the system is functioning properly. This bubbling indicates that suction is being applied and that the chest tube is effectively draining fluid or air from the patient's pleural space. It is essential for the nurse to understand the normal functioning of the chest tube drainage system to differentiate between expected and concerning findings. Adjusting the dial on the wall regulator (Option A) is not necessary in this situation because the bubbling indicates that the suction is working correctly. Documenting the presence of a large air leak (Option C) may lead to unnecessary alarm if the bubbling is due to the expected suction. Notifying the surgeon of a possible pneumothorax (Option D) is premature without further assessment or evidence of a complication. Educationally, understanding the rationale behind the expected findings in chest tube management is crucial for nurses caring for patients with thoracic surgeries. This knowledge ensures appropriate and timely interventions, prevents unnecessary actions that may disrupt patient care, and promotes safe and effective nursing practice in managing chest tubes and drainage systems. Nurses must be equipped with the knowledge and critical thinking skills to assess, interpret, and respond to chest tube drainage system findings accurately to provide optimal care for their patients.