A patient is diagnosed with a large pulmonary embolism. When explaining to the patient what has happened to cause respiratory failure, which information will the nurse include?

Correct Answer: D

Rationale: The correct answer is D because in a large pulmonary embolism, a blood clot obstructs blood flow in the pulmonary arteries, leading to decreased blood flow to parts of the lungs despite adequate breathing. This mismatch between ventilation and perfusion causes respiratory failure. A is incorrect because thick membranes between air sacs and lung circulation do not play a significant role in pulmonary embolism. B is incorrect as it describes bronchial blockage, not pulmonary embolism. C is incorrect because it describes a mismatch in ventilation and perfusion but does not specifically relate to decreased blood flow due to a pulmonary embolism.

Correct Answer: D

Rationale: The correct answer is D because in acute respiratory failure, the goal is to maintain adequate oxygenation while avoiding oxygen toxicity. Keeping PaO2 at ≥60 mm Hg ensures tissue oxygenation without causing harm. Low-flow devices like nasal cannula (A) may not provide sufficient oxygen. Correcting PaO2 to normal levels quickly (B) can lead to oxygen toxicity. Positive-pressure ventilation (C) is indicated in severe respiratory failure, not for all patients in acute respiratory failure.

Correct Answer: C

Rationale: The student nurse should first check the level of suction on the wall because the absence of bubbling in the suction control chamber indicates a potential issue with the suction level. Checking the suction setting ensures that the chest tube is functioning properly. Documenting this as normal (choice A) is incorrect because it could lead to overlooking a problem. Encouraging the patient to cough and deep breathe (choice B) is not relevant to addressing the issue with the chest tube. Clamping the chest tube and calling for help (choice D) is dangerous and could compromise the patient's condition. Therefore, checking the suction level on the wall (choice C) is the appropriate initial action to take.

Correct Answer: A

Rationale: The correct answer is A. The staff nurse should first directly address the inappropriate behavior with the hiring manager. By clearly stating that the conduct causes discomfort and requesting it to stop immediately, the nurse sets clear boundaries and asserts their rights. This action establishes a record of the nurse's response to the misconduct and gives the hiring manager the opportunity to rectify the situation. It also empowers the nurse to advocate for themselves in a professional manner. Summary: - B: Reporting to the nurse manager can be done after addressing the hiring manager directly. - C: Creating a written document can be important but should follow direct communication. - D: Seeking help from a friend can provide support but should not replace direct confrontation with the hiring manager.

Correct Answer: D

Rationale: The correct answer is D. The nurse should have the AP check to see if the elbow restraint is in place for the infant postoperative from cleft palate surgery first. This task is a safety priority to ensure the infant's postoperative care and prevent any complications related to the surgical correction. It requires immediate attention to prevent injury or complications. Choices A, B, and C are important tasks but not as urgent as ensuring the safety and well-being of a postoperative infant. Collecting a stool sample, engaging a toddler in play, and washing the hair of an adolescent can be done after ensuring the immediate safety and well-being of the postoperative infant.