A patient with severe respiratory distress is admitted. What is the nurse's priority action?

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: 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.

Correct Answer: A

Rationale: The correct answer is A: Administer supplemental oxygen. This is the priority intervention for a patient with a suspected pulmonary embolism because it helps improve oxygenation and prevents further hypoxia. Oxygen therapy is crucial in stabilizing the patient's condition and should be initiated promptly. Summary of other choices: B: Notifying the healthcare provider is important, but administering oxygen takes precedence due to the immediate need for oxygenation. C: While a CT scan is important for confirming the diagnosis, providing oxygen is more urgent to address the patient's hypoxia. D: Starting anticoagulant therapy is a critical treatment for pulmonary embolism, but ensuring oxygenation is the immediate priority to stabilize the patient's condition.

Correct Answer: B

Rationale: The correct answer is B: Kussmaul respirations. The ABG results indicate metabolic acidosis (low pH, low HCO3-), causing respiratory compensation to lower PaCO2. Kussmaul respirations are deep, rapid breaths to blow off CO2 and normalize pH. Intercostal retractions (A) are seen in respiratory distress, not metabolic acidosis. Low SpO2 (C) is not directly related to the ABG results. Decreased venous O2 pressure (D) is not a typical finding in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Administer insulin therapy. When a patient is at risk for hypoglycemia, administering insulin can further decrease blood sugar levels, exacerbating the condition. Therefore, the nurse should not administer insulin, glucose, or a snack, as these interventions can worsen hypoglycemia. Administering insulin therapy would be counterproductive and potentially harmful in this situation, making it the correct choice.