A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient?

Correct Answer: B

Rationale: The correct answer is B because during an acute situation like respiratory distress, the nurse should prioritize gathering specific information about the current episode to assess the severity and potential causes promptly. This allows for timely interventions and prevents further complications. Choices A, C, and D are incorrect because: A - It is not appropriate to ask the patient to lie down immediately without gathering vital information first. C - Checking for allergies is important but not the priority in an acute situation. D - Delaying the physical assessment for pulmonary function tests can lead to a delay in providing necessary interventions.

Correct Answer: C

Rationale: The correct answer is C: Hold the breath for 10 seconds after inhalation. This instruction is important for ensuring proper medication delivery to the lungs. Holding the breath allows the medication to reach deeper into the lungs. Option A is incorrect because DPIs should not be shaken. Option B is incorrect as exhaling into the inhaler can lead to contamination. Option D is incorrect because rinsing the mouth is typically advised for using corticosteroid inhalers, not DPIs. Holding the breath is crucial for optimal drug deposition in the lungs.

Correct Answer: A

Rationale: The correct answer is A because an oxygen saturation of 87% indicates severe hypoxemia, requiring immediate intervention to prevent complications like respiratory failure. Greenish sputum (B) suggests a possible bacterial infection but doesn't require immediate action. Fever (C) and a respiratory rate within normal range (D) are common findings in pneumonia and can be managed appropriately without immediate concern.

Correct Answer: B

Rationale: The correct answer is B. An oxygen saturation of 89% on room air indicates hypoxemia, which can be life-threatening and requires immediate intervention. This finding suggests inadequate oxygenation and potential respiratory distress. Choice A is within the normal range for respiratory rate. Choice C is expected after thoracentesis. Choice D, although a large amount of drainage, does not indicate an immediate concern for patient safety. In summary, the critical finding is hypoxemia, which necessitates prompt healthcare provider notification to prevent further complications.

Correct Answer: B

Rationale: The correct answer is B because chest tube drainage of 200 mL in the first hour after thoracotomy indicates active bleeding or a significant air leak, requiring immediate intervention to prevent complications like tension pneumothorax or hemorrhage. A: Oxygen saturation of 91% is concerning but not immediately life-threatening. C: Subcutaneous emphysema is expected post-thoracotomy and may not require immediate intervention. D: Diminished breath sounds may indicate a complication but are not as urgent as significant chest tube drainage.