A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important?

Correct Answer: A

Rationale: The correct answer is A) Teach the patient to keep the mask on during meals. This is important because interrupting oxygen therapy during meals can lead to a decrease in oxygen saturation levels, potentially causing hypoxia in the patient. Maintaining consistent oxygen delivery is crucial for patients who require supplemental oxygen to support their oxygenation needs. Option B) Keep the air entrainment ports clean and unobstructed, although important for maintaining the functionality of the Venturi mask, is not directly related to ensuring the correct amount of oxygen delivery in this specific scenario. Option C) Giving a high enough flow rate to keep the bag from collapsing is not necessary with a Venturi mask, as the device is designed to deliver a precise oxygen concentration regardless of the flow rate. Option D) Draining moisture condensation from the corrugated tubing every hour is important for preventing infection and maintaining the integrity of the equipment but does not directly impact the correct amount of oxygen delivery in this case. In an educational context, it is crucial for nurses to understand the principles of oxygen therapy and how to ensure appropriate oxygen delivery to patients. Teaching patients about the importance of consistent oxygen therapy, especially during meals, is a key aspect of providing safe and effective care to individuals requiring oxygen supplementation.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Check the ventilator settings. This is the priority intervention because the patient's signs of respiratory distress indicate a potential issue with the mechanical ventilation. Checking the ventilator settings allows the nurse to assess if the settings are appropriate for the patient's current condition and make any necessary adjustments to improve oxygenation. Monitoring the patient's blood pressure (option B) is important in overall patient assessment, but in this case, addressing the respiratory distress takes precedence as it directly impacts oxygenation and can lead to serious complications if not managed promptly. Administering IV fluids (options C and D) is not the priority in this situation as the patient is experiencing respiratory distress, which requires immediate attention to ensure adequate oxygenation. IV fluids may be needed depending on the patient's overall condition, but addressing the respiratory distress should come first to prevent further deterioration. In an educational context, understanding the priority interventions in a critical care setting like mechanical ventilation is crucial for nurses to provide safe and effective care. By prioritizing actions based on the patient's condition, nurses can intervene promptly to optimize outcomes and prevent complications related to oxygenation.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Administer pain relief. The priority action for a patient with COPD experiencing pain is to provide pain relief to alleviate their discomfort. Pain can exacerbate respiratory distress in patients with COPD, leading to increased work of breathing and potential complications. Addressing pain promptly not only improves the patient's comfort but also supports their respiratory function. Option A) Administer oxygen therapy may seem like a logical choice, but in this case, addressing the patient's pain takes precedence over oxygen therapy as pain can worsen respiratory distress. Option B) Administer morphine for pain relief is incorrect as it duplicates the correct answer but adds a specific medication. Providing pain relief without specifying a medication allows for flexibility in choosing the most appropriate pain relief intervention based on the patient's individual needs and condition. Option D) Administer insulin therapy is irrelevant to the patient's immediate needs in managing COPD and is not a priority action in this situation. Educationally, understanding the priority of interventions in managing COPD is crucial for nurses caring for these patients. Pain management plays a significant role in improving patient outcomes and should be promptly addressed to enhance patient comfort and support respiratory function. Nurses must prioritize interventions based on the patient's condition and individual needs to provide safe and effective care.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Administer insulin. The priority action is to address the patient's complaint of blurry vision, which can be a sign of hyperglycemia in a patient with diabetes. Administering insulin is crucial to lower the elevated blood glucose levels that may be causing the blurry vision and prevent potential complications like diabetic retinopathy. Option A) Monitor blood glucose levels is not the priority in this situation because the patient is already experiencing symptoms of hyperglycemia, and prompt intervention is needed. Option B) Administer a nebulizer is not relevant to the patient's complaint of blurry vision, which is likely related to the uncontrolled blood glucose levels. Option D) Monitor vital signs is important but not the immediate priority when the patient is experiencing a symptom that indicates a potential diabetic emergency. Educationally, this question highlights the importance of recognizing early signs of hyperglycemia in patients with diabetes and the need for prompt intervention to prevent complications. Understanding the link between diabetes, hyperglycemia, and ocular complications is crucial for nurses to provide safe and effective care for diabetic patients.

Correct Answer: A

Rationale: The correct answer is A) Allergy to shellfish. Communicating this information to the health care provider is a priority before the CT scan because the patient may have a contrast dye allergy, often derived from shellfish, which could lead to a severe allergic reaction during the scan. This crucial information allows the provider to take necessary precautions to prevent a potentially life-threatening situation. Option B) Apical pulse of 104 is not the priority as it may be within normal limits considering the patient's acute dyspnea. Option C) Respiratory rate of 30 is also important but not as critical as the allergy information. Option D) O₂ saturation of 90% is concerning but may be due to the underlying dyspnea, whereas the allergy poses an immediate risk. Educationally, this question highlights the importance of thorough assessment and communication of critical information to ensure patient safety during diagnostic procedures. It emphasizes the significance of recognizing and prioritizing patient data to guide appropriate nursing interventions and collaborative care with healthcare providers.