A patient recovering from a thoracotomy has new-onset shortness of breath. What is the nurse's priority action?

Correct Answer: C

Rationale: The correct answer is C because assessing oxygen saturation and lung sounds is crucial in determining the patient's respiratory status. This helps identify potential complications like pneumothorax or atelectasis, which are common after thoracotomy. Deep breaths (A) can worsen conditions like pneumothorax. Notifying the healthcare provider (B) may delay immediate action. Administering bronchodilators (D) is not appropriate without a comprehensive assessment.

Correct Answer: A

Rationale: The correct answer is A: Adherence to the full course of prescribed medications. This is the priority teaching point because adherence to the full course of TB medications is crucial to ensure complete eradication of the bacteria and prevent the development of drug-resistant strains. Skipping doses or stopping treatment prematurely can lead to treatment failure and the spread of TB. Choice B is incorrect because avoiding contact with family members during treatment is not necessary as TB is not spread through casual contact. Choice C is incorrect as completing follow-up skin tests every six months is not the priority teaching point, although it may be part of the follow-up care plan. Choice D is incorrect as using a surgical mask when going outdoors is not necessary unless the patient is actively coughing and symptomatic.

Correct Answer: D

Rationale: The correct answer is D: Discuss the need for an injectable antibiotic with the health care provider. If a patient continues to have positive sputum smears for AFB after 2 months of standard TB treatment, it suggests drug resistance. The next step would be to consider adding an injectable antibiotic like amikacin or streptomycin to the treatment regimen. This decision should be made in consultation with the healthcare provider based on culture and sensitivity testing results. A: Teaching about drug-resistant TB is important, but the immediate action should be to adjust the treatment regimen. B: Scheduling directly observed therapy may help with medication adherence but does not address the need for a change in treatment. C: Asking about medication adherence is important, but if the patient has been compliant, a change in treatment is necessary.

Correct Answer: B

Rationale: The correct answer is B: Instruct the patient to elevate the foot. Elevating the foot helps reduce swelling, improve circulation, and promote wound healing in patients with foot ulcers. By elevating the foot, the pressure on the ulcer is reduced, which can prevent further damage and aid in the healing process. Encouraging the patient to wear shoes (A) may be important for protection, but it is not the priority over immediate wound care. Performing a sterile dressing change (C) and applying antibiotic ointment (D) are important interventions, but they should be done after elevating the foot to address the underlying issue of poor circulation and pressure on the ulcer.

Correct Answer: B

Rationale: The correct answer is B: Administer nitroglycerin. Nitroglycerin is the priority intervention because chest pain in a patient with a history of hypertension could indicate angina or a possible myocardial infarction. Nitroglycerin helps dilate blood vessels, reduce workload on the heart, and improve blood flow to the heart muscle, which can alleviate chest pain. Administering aspirin can also be beneficial to prevent clot formation, but nitroglycerin takes precedence in this situation. Providing reassurance and support is important but should not delay immediate treatment. Administering IV fluids is not indicated for chest pain in this scenario.