A patient with pneumonia has a fever of 101.4°F (38.6°C), a nonproductive cough, and an O₂ saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the priority?

Correct Answer: D

Rationale: The priority nursing diagnosis in this scenario is "D) Impaired gas exchange related to respiratory congestion." Rationale: Impaired gas exchange is the priority because the patient's O₂ saturation is only 88%, indicating inadequate oxygenation. This poses a serious threat to the patient's health and needs immediate intervention to prevent hypoxia and further complications like respiratory failure. Why others are wrong: A) Hyperthermia related to infectious illness: While fever is present, it is not the immediate threat to the patient's well-being. Oxygenation takes precedence over managing fever. B) Impaired transfer ability related to weakness: While weakness is a concern, it is secondary to the critical issue of impaired gas exchange affecting oxygen delivery to vital organs. C) Ineffective airway clearance related to thick secretions: While this is important, the priority is to ensure that the patient is able to oxygenate adequately to support vital functions. Educational context: Understanding the prioritization of nursing diagnoses is crucial in providing effective and efficient patient care. In acute situations like respiratory distress, addressing impaired gas exchange promptly can make a significant impact on patient outcomes. Nurses must be able to differentiate between urgent and non-urgent issues to prioritize care effectively and ensure patient safety.

Correct Answer: D

Rationale: The correct answer is D because the patient's asthma is not well-controlled with only short-acting bronchodilators like albuterol (Ventolin HFA) and long-acting bronchodilators like salmeterol (Serevent). This combination does not address the underlying inflammation in asthma. The patient needs an inhaled corticosteroid as maintenance therapy to control inflammation and prevent exacerbations. Option A is incorrect because using albuterol before exercise is a common practice to prevent exercise-induced bronchospasm in asthma patients. Option B is incorrect because worsening symptoms in spring could be related to seasonal allergens triggering asthma, which may require adjustment in therapy, but it does not necessarily indicate a need for an immediate change. Option C is incorrect because an increase in heart rate after using albuterol is an expected side effect due to its bronchodilator properties and does not necessarily indicate a need for a change in therapy unless there are other concerning symptoms present. In an educational context, it is vital for nurses to understand asthma management principles to provide optimal care for patients. Recognizing when a patient's current therapy is inadequate and needs adjustment is crucial in preventing asthma exacerbations and improving quality of life. Incorporating evidence-based guidelines in asthma management helps nurses make informed decisions in patient care.

Correct Answer: D

Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99.' After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion.

Correct Answer: A

Rationale: In caring for a patient with a tracheostomy tube, maintaining safe cuff pressure is essential to prevent complications such as tracheal mucosal damage or aspiration. The correct answer, option A, "Measure with a manometer," is the most appropriate way to ensure safe cuff pressure. Using a manometer allows the nurse to accurately measure the pressure inside the cuff of the tracheostomy tube. This is crucial because overinflating the cuff can lead to tracheal damage, while underinflation can result in aspiration of secretions. Therefore, regular monitoring and adjustment of cuff pressure using a manometer is the recommended practice to ensure patient safety. Option B, "Insert decannulation plug," is incorrect as a decannulation plug is used to block the tracheostomy tube during temporary removal, not for monitoring cuff pressure. Option C, "Obtain a provider's order," is incorrect because while healthcare provider input is important in many situations, routine monitoring and adjustment of cuff pressure can and should be done by the nurse based on best practices. Option D, "Use a nonfenestrated cannula," is incorrect as it pertains to a different aspect of tracheostomy care and does not address cuff pressure monitoring. Educationally, it is essential for nurses to understand the proper care and management of tracheostomy tubes to ensure patient safety and optimal outcomes. Regular assessment, monitoring, and maintenance of cuff pressure are key components of tracheostomy care that nurses should be proficient in to provide high-quality care to patients with artificial airways.

Correct Answer: C

Rationale: Rationale: The correct answer is C) On 2 to 3 consecutive days. When obtaining sputum specimens for Mycobacterium tuberculosis testing, it is essential to collect samples on multiple consecutive days. This practice increases the likelihood of detecting the presence of the bacteria, as the concentration of Mycobacterium tuberculosis in sputum can vary from day to day. By collecting samples over several days, healthcare providers have a better chance of capturing the bacteria if it is present in the respiratory secretions. Option A) All at once is incorrect because a single sample may not capture the bacteria if it is not present in that specific sample. Mycobacterium tuberculosis can be intermittent in sputum, and a one-time collection may result in a false negative. Option B) Via blood cultures is incorrect because Mycobacterium tuberculosis is not typically detected in blood cultures. Sputum is the primary specimen used for testing for this bacterium. Option D) Via chest x-ray is incorrect because while a chest x-ray can show signs of tuberculosis infection in the lungs, it is not a method for obtaining sputum specimens for testing the presence of Mycobacterium tuberculosis directly. Educational Context: Understanding the proper procedure for collecting sputum specimens for Mycobacterium tuberculosis testing is crucial for healthcare professionals, especially those working in settings where tuberculosis is prevalent. By collecting samples on consecutive days, providers can increase the sensitivity of the diagnostic test and improve the chances of detecting the bacterium if it is present. This practice helps in accurate diagnosis, appropriate treatment initiation, and effective control of tuberculosis transmission in the community.