A patient with tuberculosis is prescribed isoniazid (INH). Which side effect should the nurse monitor for?

Correct Answer: A

Rationale: In the context of oxygen therapy, understanding the side effects of medications commonly prescribed to patients receiving this treatment is crucial for nurses. In this scenario, the correct answer is A) Peripheral neuropathy. Isoniazid (INH) is a medication used to treat tuberculosis but is known to cause peripheral neuropathy as a side effect. This condition is characterized by damage to the peripheral nerves, leading to symptoms like numbness, tingling, and weakness in the extremities. Option B) Orange discoloration of body fluids is not a known side effect of isoniazid and is more commonly associated with medications like rifampin. Option C) Visual changes are not typically linked to isoniazid use but can occur with other medications or conditions. Option D) Hearing loss is not a recognized side effect of isoniazid but may be seen with certain antibiotics like aminoglycosides. Educationally, this question highlights the importance of monitoring for specific side effects of medications, especially in patients with tuberculosis who are already vulnerable. Nurses need to be vigilant in assessing for potential adverse reactions to provide safe and effective care to their patients undergoing treatment with isoniazid.

Correct Answer: B

Rationale: In the context of oxygen therapy and pneumonia, an oxygen saturation of 84% on room air (Option B) requires immediate intervention. Oxygen saturation below 90% indicates hypoxemia, which can be life-threatening, especially in pneumonia where adequate oxygenation is crucial. Administering supplemental oxygen would help improve oxygen saturation and prevent further complications. Option A, a productive cough with green sputum, is common in pneumonia but does not indicate an immediate need for intervention. Option C, crackles over lung bases, are expected in pneumonia but do not require urgent action unless accompanied by severe respiratory distress. Option D, a respiratory rate of 22 breaths per minute, is within the normal range and does not signal an immediate need for intervention in this scenario. Educationally, understanding the significance of oxygen saturation levels in pneumonia is vital for healthcare professionals managing such patients. Prompt recognition and appropriate management of hypoxemia can improve patient outcomes and prevent respiratory failure. Regular monitoring of oxygen saturation levels and prompt intervention when levels drop below acceptable ranges are key components of effective pneumonia management.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Administer pain medication. When a patient with rib fractures experiences difficulty breathing, the priority is to address the pain, as deep breathing might exacerbate their discomfort. Pain management is crucial in allowing the patient to breathe effectively and preventing complications such as respiratory distress. Option A) Encouraging shallow breathing to reduce pain is incorrect because it does not address the underlying issue of pain management and may lead to ineffective breathing patterns. Option C) Applying a rib binder is not the first action to take as it may further restrict the patient's breathing and should be done under medical supervision. Option D) Positioning the patient for comfort is important, but addressing the pain should take precedence in this situation to ensure effective breathing. Educationally, this question highlights the importance of prioritizing patient care interventions based on the immediate needs of the patient. Understanding the implications of rib fractures on breathing and the significance of pain management in promoting optimal respiratory function are key concepts for nurses caring for patients with chest injuries.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Administer a prescribed rescue inhaler. During an acute asthma exacerbation, when the peak flow meter reading falls into the yellow zone, it indicates a significant decline in lung function and potential airway constriction. Administering a rescue inhaler, usually containing a bronchodilator such as albuterol, helps to quickly open up the airways, providing prompt relief and improving airflow. Option A is incorrect because simply encouraging the patient to rest and retrying in 15 minutes could lead to a delay in administering necessary medication, risking further deterioration of the patient's condition. Option C is incorrect because while contacting the healthcare provider is important, immediate intervention in the form of the rescue inhaler is crucial for addressing the acute symptoms and preventing escalation. Option D is incorrect as increasing the oxygen flow rate is not the recommended initial action for an asthma exacerbation. Oxygen therapy may be considered later if the patient's oxygen saturation drops, but the priority in this case is to address the bronchoconstriction with a rescue inhaler. In an educational context, it is essential for nurses and healthcare providers to understand the appropriate interventions for managing acute asthma exacerbations based on peak flow meter readings. Prompt recognition of the yellow zone and timely administration of a rescue inhaler can help prevent respiratory distress and improve patient outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Administer prescribed oxygen therapy. The priority in this situation is to address the decreased oxygen saturation level of 89% in a patient with pneumonia. Oxygen therapy is vital to improve oxygenation and support vital organ functions. Without adequate oxygenation, the patient is at risk of hypoxia, which can lead to tissue damage and organ failure. Option A) Encouraging deep breathing and coughing is important for airway clearance and respiratory function but is not the priority when the patient's oxygen saturation is significantly low. Option C) Notifying the healthcare provider immediately may be necessary but providing oxygen therapy should be the initial nursing intervention to address the immediate oxygenation needs of the patient. Option D) Preparing the patient for a chest x-ray may be indicated to further assess the pneumonia, but addressing the low oxygen saturation level should take precedence to prevent hypoxia and its complications. In an educational context, this question highlights the importance of prioritizing nursing interventions based on the patient's condition. Understanding the critical nature of oxygen therapy in respiratory distress situations is crucial for nurses to provide safe and effective care to patients with compromised oxygenation.