A patient reports coughing up rust-colored sputum. Which condition should the nurse suspect?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Pneumococcal pneumonia. Rust-colored sputum is a classic indicator of pneumococcal pneumonia, caused by Streptococcus pneumoniae. This bacterium leads to the destruction of lung tissue, causing bleeding and the presence of rusty-colored sputum. Understanding this connection is crucial for nurses to accurately assess and diagnose patients presenting with this symptom. Option A) Tuberculosis typically presents with a chronic cough, blood-tinged sputum, weight loss, and night sweats. While tuberculosis can cause hemoptysis, it does not usually result in rust-colored sputum. Option B) Pulmonary embolism manifests with sudden onset shortness of breath, chest pain, and coughing up blood. Rust-colored sputum is not a common presentation of pulmonary embolism. Option D) Bronchitis is characterized by a productive cough with clear, white, yellow, or green sputum. Rust-colored sputum is not typically associated with bronchitis. Educationally, understanding the specific sputum characteristics associated with different respiratory conditions is vital for accurate clinical assessments and interventions. Nurses must be able to differentiate between various respiratory conditions based on presenting symptoms to provide timely and appropriate care to patients.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Oxygen saturation of 84% on room air. This finding requires immediate action because it indicates severe hypoxemia, which can lead to serious complications such as organ damage and respiratory failure. Oxygen saturation below 90% is considered low and requires intervention to prevent further deterioration of the patient's condition. Option A (Temperature of 101.3°F) may be indicative of infection but does not require immediate action as it is not life-threatening in the same way as severe hypoxemia. Option B (Productive cough with yellow sputum) is common in pneumonia but does not indicate an immediate need for intervention. Option D (Coarse crackles heard in the lung bases) may suggest fluid in the lungs but does not require immediate action as addressing hypoxemia is the priority in this case. Educationally, this question highlights the importance of recognizing and prioritizing critical assessment findings in patients with respiratory conditions. Understanding the significance of oxygen saturation levels and the potential consequences of severe hypoxemia is crucial for healthcare providers to deliver prompt and effective care to patients in respiratory distress.

Correct Answer: A

Rationale: In this scenario, the correct answer is to position the patient in a semi-Fowler's position (Option A) as the first action. Placing the patient in a semi-Fowler's position helps improve oxygenation and facilitates breathing by reducing pressure on the chest and promoting lung expansion. This position also helps in relieving chest pain and can aid in the management of hemoptysis (coughing up blood). Notifying the healthcare provider immediately (Option B) is important, but the immediate action should be to address the patient's comfort and oxygenation first. Administering oxygen at 2 L/min (Option C) could be beneficial, but without knowing the underlying cause of the symptoms, it may not be the most appropriate initial action. Performing a respiratory assessment (Option D) is important but should come after ensuring the patient's immediate comfort and safety. In an educational context, this question highlights the importance of prioritizing interventions based on the patient's presenting symptoms. It emphasizes the significance of assessing and addressing urgent needs promptly to ensure patient safety and well-being. Understanding the rationale behind the correct action helps nurses develop critical thinking skills and clinical judgment in emergency situations.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Oxygen saturation levels. When a patient with COPD experiences worsening shortness of breath, assessing oxygen saturation levels is critical because hypoxemia can significantly impact their condition. Low oxygen saturation levels can indicate respiratory distress and the need for supplemental oxygen therapy to improve oxygenation and alleviate symptoms. Option A) Respiratory rate and effort is important in assessing respiratory status, but in a patient with COPD experiencing worsening shortness of breath, checking oxygen saturation levels takes precedence as it provides more immediate information about oxygen exchange. Option C) Lung sounds for wheezing or crackles are important in assessing respiratory conditions, but in this case, the priority is to determine the oxygenation status of the patient. Option D) Peak expiratory flow rate is more commonly used in conditions like asthma to monitor airway obstruction, and it is not the first assessment to perform in a COPD patient with worsening shortness of breath. Educationally, understanding the prioritization of assessments in patients with COPD is crucial for nurses and healthcare providers to effectively manage and intervene in respiratory distress situations. By recognizing the significance of assessing oxygen saturation levels promptly, healthcare professionals can make timely interventions to improve patient outcomes and prevent respiratory complications.

Correct Answer: B

Rationale: In a patient with acute bronchitis, an oxygen saturation of 89% requires immediate attention. Oxygen saturation below 90% indicates hypoxemia, which can lead to serious complications such as respiratory failure and organ damage. Addressing this low oxygen level promptly is crucial to prevent further deterioration and ensure adequate oxygen delivery to the body's tissues. The other options are not as immediately concerning as a low oxygen saturation level. - A persistent dry cough is a common symptom of bronchitis but does not indicate an immediate threat to the patient's condition. - Coarse crackles in both lungs may suggest the presence of mucus or inflammation but do not necessarily require immediate intervention. - Increased sputum production is a typical symptom of bronchitis and may indicate the body's response to infection but does not pose an immediate threat to the patient's oxygenation. Educationally, understanding the significance of oxygen saturation levels in respiratory conditions is vital for healthcare providers to prioritize interventions and provide timely, effective care. Monitoring and interpreting oxygen saturation levels accurately can help prevent complications and guide treatment decisions in patients with respiratory illnesses like acute bronchitis.