A patient with pneumonia reports sharp chest pain that worsens with deep breathing. What should the nurse do first?

Correct Answer: B

Rationale: The correct answer is B because auscultating the lungs for breath sounds will help assess the severity and distribution of the pneumonia. This step is vital in determining the appropriate treatment and intervention. Administering pain reliever (Choice A) may mask symptoms and delay proper assessment. Encouraging deep breaths (Choice C) can exacerbate the pain. Placing the patient in a high Fowler's position (Choice D) may provide comfort but does not address the immediate need for assessment.

Correct Answer: C

Rationale: Certainly. The correct answer is C, providing oral care with chlorhexidine. This action helps reduce the risk of VAP by decreasing the oral bacterial load, preventing aspiration of pathogens into the lungs. Suctioning the airway every 2 hours (A) can irritate the airway and increase the risk of infection. Administering antibiotics prophylactically (B) can lead to antibiotic resistance and should be reserved for specific indications. Keeping the patient sedated (D) may increase the risk of aspiration due to reduced cough reflex.

Correct Answer: B

Rationale: The correct answer is B because in a critical situation like severe respiratory distress, immediate actions are crucial. Asking focused questions about the current episode will provide essential information for quick decision-making and interventions. It helps in assessing the severity of the distress, identifying potential causes, and determining the appropriate initial treatment. Obtaining a comprehensive health history (choice A) can be important but not urgent in this acute situation. Delaying assessment for pulmonary function tests (choice C) can be detrimental as it can delay necessary interventions. Checking for allergies before treatment (choice D) is important but not the priority when the patient is in severe distress.

Correct Answer: C

Rationale: The correct answer is C: Provide low-flow oxygen therapy. In COPD, hypoxemia (low PaO2) is the primary concern. Administering oxygen can help improve oxygenation and prevent further complications. Bronchodilators (choice A) may be indicated for symptom relief but not the priority. Pursed-lip breathing (choice B) can help with exhalation and symptom management but does not address the immediate hypoxemia. Assessing the patient's level of consciousness (choice D) is important but providing oxygen to improve oxygenation takes precedence in this case.

Correct Answer: C

Rationale: Rationale: Choice C indicates the need for further teaching because forcefully exhaling after inhaling the medication can reduce the amount of medication reaching the lungs. The correct technique is to hold the breath for 10 seconds to allow the medication to be absorbed effectively. Choices A, B, and D are all correct techniques for using a metered-dose inhaler and do not indicate the need for further teaching.