A nurse is caring for a patient with a history of chronic obstructive pulmonary disease (COPD) who is receiving oxygen therapy. The patient's oxygen saturation is 87%. What is the priority action?

Correct Answer: C

Rationale: The correct answer is C: Administer oxygen therapy. In a patient with COPD and oxygen saturation of 87%, the priority action is to ensure adequate oxygenation. Administering oxygen therapy will help improve oxygen saturation levels and prevent hypoxemia. Increasing the flow rate of oxygen (choice A) may lead to oxygen toxicity. Administering a nebulized bronchodilator (choice B) can help with bronchodilation but does not address the immediate need for oxygenation. Administering corticosteroids (choice D) may be indicated for COPD exacerbations but is not the priority in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. The priority action in this scenario is to address the chest pain, which could be indicative of a myocardial infarction or heart attack. Nitroglycerin helps to dilate blood vessels, improve blood flow to the heart, and relieve chest pain. Administering nitroglycerin promptly can help alleviate the patient's symptoms and potentially prevent further cardiac damage. Choice B (Administer aspirin) is also a common intervention for chest pain, but nitroglycerin is the priority as it directly addresses the underlying cause of chest pain in this case. Choice C (Monitor vital signs) and choice D (Administer IV fluids) are important interventions but are not the priority when a patient with a history of hypertension presents with chest pain, as addressing the potential cardiac issue should be the primary focus.

Correct Answer: C

Rationale: The correct answer is C: Administer oxygen therapy. Priority intervention is ensuring adequate oxygenation to the patient recovering from surgery. Oxygen therapy helps improve oxygen levels, vital for proper healing and recovery. Administering diuretics (A) is not a priority as the patient's pain needs immediate attention. IV fluids (B) may be necessary, but addressing pain and oxygenation come first. Administering antibiotics (D) is not indicated if the primary concern is pain and oxygen levels.

Correct Answer: B

Rationale: The correct answer is B) Kussmaul respirations. In this scenario, the patient's ABG results show a low pH and low HCO₃⁻ levels, indicating metabolic acidosis. Kussmaul respirations are a compensatory mechanism the body uses to try to lower the acidity in the blood by blowing off excess CO₂ through rapid and deep breathing. This is commonly seen in conditions like diabetic ketoacidosis, where the body is trying to correct the acid-base imbalance. Option A) Intercostal retractions are not typically associated with the ABG results provided in the question. Intercostal retractions are usually seen in conditions where there is increased work of breathing, such as respiratory distress or obstruction. Option C) Low oxygen saturation (SpO₂) is not specifically indicated by the ABG results provided. While the PaO₂ is 85 mm Hg, which is slightly on the lower side, it does not directly correlate with low oxygen saturation. Option D) Decreased venous O₂ pressure is not a typical finding related to the ABG results provided. Venous O₂ pressure is not directly assessed through arterial blood gas measurements and is not relevant in this context. Educationally, understanding how to interpret ABG results is crucial for nurses to provide safe and effective care to their patients. Recognizing the significance of findings like pH, PaCO₂, PaO₂, and HCO₃⁻ can help nurses identify potential underlying conditions and provide appropriate interventions to manage these conditions effectively.

Correct Answer: C

Rationale: The correct answer is C) Put on sterile gloves and use a sterile catheter to suction. When coarse crackles are heard on auscultation of a patient with a tracheostomy tube, it indicates the presence of secretions that need to be cleared to maintain airway patency. Sterile suctioning is the appropriate intervention to effectively remove these secretions and prevent respiratory compromise. Option A) Encouraging increased incentive spirometer use is not the priority in this situation as it does not address the immediate need for airway clearance. Option B) Encouraging the patient to increase oral fluid intake may not be effective in clearing the secretions that are causing the coarse crackles. Option D) Preoxygenating the patient for 3 minutes before suctioning is not the correct action to take when immediate airway clearance is needed due to the presence of secretions. In an educational context, it is crucial for nurses to understand the significance of auscultation findings like coarse crackles in patients with tracheostomy tubes. Prompt and appropriate intervention, such as sterile suctioning, is essential in maintaining airway patency and preventing respiratory complications in patients with compromised airways. Nurses must be skilled in performing suctioning procedures safely and effectively to provide optimal care for patients with tracheostomies.