A patient with severe respiratory distress has a PaO2 of 48 mm Hg. What should the nurse do first?

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen therapy immediately. In severe respiratory distress with a PaO2 of 48 mm Hg, the priority is to improve oxygenation. Administering oxygen therapy will help increase the PaO2 levels quickly, improving oxygen delivery to vital organs. Positioning the patient in high Fowler's (B) can help with breathing but does not address the immediate need for oxygen. Intubation (C) may be necessary but is not the first step. Notifying the healthcare provider (D) can cause delays in providing essential oxygen therapy.

Correct Answer: B

Rationale: The correct interpretation is uncompensated respiratory acidosis (Choice B). Step-by-step rationale: 1. pH is low (acidosis): Indicates an acid-base imbalance. 2. PaCO2 is high (55 mm Hg): Indicates respiratory acidosis. 3. HCO3- is within normal range (24 mEq/L): Indicates no compensation by the kidneys. Therefore, the patient is experiencing respiratory acidosis without compensatory metabolic changes. Other choices are incorrect: A: Metabolic acidosis: HCO3- is within normal range. C: Partially compensated metabolic acidosis: PaCO2 is high, not low. D: Compensated respiratory alkalosis: pH is low, indicating acidosis.

Correct Answer: B

Rationale: The correct answer is B: Provide oxygen therapy as needed. In a patient with a pulmonary embolism, ensuring adequate oxygenation is the priority to prevent hypoxia and tissue damage. Oxygen therapy helps improve oxygen saturation levels, reducing the workload on the heart and lungs. Administering anticoagulants (Choice A) is important but not the immediate priority. Positioning in high Fowler's (Choice C) may help with breathing but doesn't address immediate oxygen needs. Notifying the healthcare provider (Choice D) is essential but not the immediate action needed to stabilize the patient.

Correct Answer: C

Rationale: The correct answer is C because a decrease in white blood cell count indicates a reduction in infection. This is a key indicator of the effectiveness of antibiotic treatment for pneumonia. A: Bronchial breath sounds indicate consolidation, which is not necessarily indicative of improvement. B: Green mucus suggests ongoing infection rather than improvement. D: Increased tactile fremitus can be present in pneumonia and may not necessarily change with treatment efficacy.

Correct Answer: B

Rationale: The correct answer is B: Monitor the patient for changes in neurological status. This is the priority intervention because patients with a history of stroke are at risk for complications such as recurrent strokes or worsening neurological status. Monitoring for changes allows for early detection and timely intervention. A: Assisting with a swallowing assessment is important, but monitoring neurological status takes precedence as it directly assesses the patient's brain function. C: Having a family member for rehabilitation is beneficial but not the priority over monitoring neurological status for immediate complications. D: Providing medication for swallowing improvement may be necessary, but monitoring neurological status is crucial for detecting any emergent issues. In summary, monitoring neurological status is the priority as it directly assesses the patient's brain function and allows for early detection of complications.