A patient is receiving antibiotics for pneumonia. Which assessment finding requires immediate follow-up?

Correct Answer: B

Rationale: The correct answer is B: Oxygen saturation of 88% on room air. This finding indicates severe hypoxemia, which is a medical emergency requiring immediate intervention to prevent hypoxia-related complications. Hypoxemia can lead to tissue damage and organ dysfunction. Immediate follow-up may involve providing supplemental oxygen and assessing the patient's respiratory status. Choice A: Temperature of 101°F is slightly elevated but not an immediate concern in the context of pneumonia treatment. Choice C: Productive cough with yellow sputum is a common symptom of pneumonia and does not require immediate follow-up unless accompanied by other concerning symptoms. Choice D: Crackles in both lung bases are expected in pneumonia and do not necessitate immediate action unless associated with respiratory distress.

Correct Answer: B

Rationale: The correct answer is B: Provide oxygen therapy as needed. In a patient with a pulmonary embolism, ensuring adequate oxygenation is the priority to prevent hypoxia and tissue damage. Oxygen therapy helps improve oxygen saturation levels, reducing the workload on the heart and lungs. Administering anticoagulants (Choice A) is important but not the immediate priority. Positioning in high Fowler's (Choice C) may help with breathing but doesn't address immediate oxygen needs. Notifying the healthcare provider (Choice D) is essential but not the immediate action needed to stabilize the patient.

Correct Answer: C

Rationale: The correct answer is C because a decrease in white blood cell count indicates a reduction in infection. This is a key indicator of the effectiveness of antibiotic treatment for pneumonia. A: Bronchial breath sounds indicate consolidation, which is not necessarily indicative of improvement. B: Green mucus suggests ongoing infection rather than improvement. D: Increased tactile fremitus can be present in pneumonia and may not necessarily change with treatment efficacy.

Correct Answer: B

Rationale: The correct answer is B: Monitor the patient for changes in neurological status. This is the priority intervention because patients with a history of stroke are at risk for complications such as recurrent strokes or worsening neurological status. Monitoring for changes allows for early detection and timely intervention. A: Assisting with a swallowing assessment is important, but monitoring neurological status takes precedence as it directly assesses the patient's brain function. C: Having a family member for rehabilitation is beneficial but not the priority over monitoring neurological status for immediate complications. D: Providing medication for swallowing improvement may be necessary, but monitoring neurological status is crucial for detecting any emergent issues. In summary, monitoring neurological status is the priority as it directly assesses the patient's brain function and allows for early detection of complications.

Correct Answer: A

Rationale: The correct answer is A. Administering intravenous fluids is the priority nursing action for a patient at risk for fluid volume deficit due to severe burns. This helps restore fluid balance and prevent complications like hypovolemic shock. Monitoring respiratory status (B) is important but not the priority in this case. Administering oral antibiotics (C) may be necessary but does not address the immediate risk of fluid deficit. Providing family support (D) is essential but not the priority when the patient's physiological needs must be addressed first.