A patient reports sudden shortness of breath and chest pain. Which condition should the nurse suspect first?

Correct Answer: B

Rationale: The correct answer is B: Pulmonary embolism. This is the most critical condition among the choices that presents with sudden shortness of breath and chest pain. Pulmonary embolism occurs when a blood clot travels to the lungs, causing blockage in the pulmonary arteries, leading to severe respiratory distress and chest pain. The other choices (Acute bronchitis, Pneumonia, and Asthma exacerbation) may also present with similar symptoms, but they typically do not manifest as suddenly and severely as a pulmonary embolism. It is crucial for the nurse to suspect and prioritize investigating a pulmonary embolism in this scenario due to its life-threatening nature and the need for immediate medical intervention.

Correct Answer: C

Rationale: Rationale for Choice C (correct answer): Suctioning a tracheostomy every 2 hours is excessive and can lead to mucosal trauma, infection, and compromised airway. Suctioning should be done only when necessary to maintain airway patency. Cleaning around the stoma, replacing soiled ties, and humidifying the air are all important aspects of tracheostomy care. Suctioning every 2 hours is not routine practice and can be harmful.

Correct Answer: C

Rationale: The presence of thick, green sputum suggests an infection with bacteria. Pneumonia is characterized by an infection in the lungs leading to sputum production. This aligns with the patient's chronic cough and sputum color. Bronchitis typically presents with clear or white sputum. Tuberculosis usually causes bloody or yellowish sputum. Pulmonary embolism does not typically cause sputum production. Therefore, option C, pneumonia, is the most likely condition based on the symptoms described.

Correct Answer: A

Rationale: The correct answer is A: Perform tracheal suctioning. When a patient with a tracheostomy is unable to clear secretions, suctioning is necessary to remove the accumulated secretions and maintain a clear airway. This prevents potential complications such as airway obstruction and respiratory distress. Administering a mucolytic (B) may help loosen secretions but does not address the immediate need for clearing them. Encouraging the patient to cough forcefully (C) may not be effective if the secretions are too thick or if the patient is unable to cough effectively. Increasing fluid intake (D) may help in thinning secretions but will not address the immediate need for clearing them.

Correct Answer: B

Rationale: The correct answer is B: Increase the patient's fluid intake. Thick pulmonary secretions can be effectively thinned out by increasing hydration, making it easier for the patient to clear the secretions through coughing and expectoration. This intervention helps to improve lung function and prevent complications such as respiratory infections. Postural drainage and percussion (Choice A) are interventions for mobilizing secretions in specific lung segments but may not address the underlying issue of thick secretions. Administering bronchodilators (Choice C) is appropriate for conditions like asthma or COPD but not directly for thick secretions. Encouraging the use of a peak flow meter (Choice D) is helpful for monitoring lung function but does not directly address the thickness of pulmonary secretions.