After change-of-shift report, which patient should the nurse assess first?

Correct Answer: D

Rationale: The correct answer is option D, the 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion, should be assessed first. Tracheal deviation indicates a potential tension pneumothorax, a critical condition where air accumulates in the pleural space under pressure, causing the lung to collapse and shifting the trachea. This situation can rapidly progress to respiratory failure and requires immediate intervention to prevent further complications, making prompt assessment crucial. Option A, the 72-year-old with cor pulmonale and bilateral edema, though concerning, does not present an immediate life-threatening condition that requires urgent assessment compared to tracheal deviation. Option B, the 28-year-old with a lung transplant and fever, may indicate infection but is not as acutely critical as tracheal deviation. Option C, the 40-year-old with pleural effusion and chest pain, while in discomfort, does not have a presentation as urgent as tracheal deviation. In an educational context, understanding the priority of patient assessment based on the urgency of their condition is essential for nurses. Recognizing critical signs like tracheal deviation and knowing the appropriate actions to take in such situations can significantly impact patient outcomes. This scenario highlights the importance of swift clinical judgment and prioritization in nursing practice to ensure timely and effective care delivery.

Correct Answer: B

Rationale: In this scenario, option B is the correct answer as blowing the nose should not be avoided to decrease the risk of nosebleeds in acute sinusitis. Blowing the nose can actually help clear out secretions and alleviate symptoms. Option A is incorrect because decongestants can indeed help relieve swelling in the sinuses, aiding in drainage and symptom relief. Option C is also incorrect as taking a hot shower can be beneficial in increasing sinus drainage and decreasing pain. Option D is incorrect as saline nasal spray is a recommended method to wash out secretions and maintain sinus hygiene. From an educational perspective, it is important for nurses to provide accurate and evidence-based information to patients when teaching about managing conditions like acute sinusitis. Understanding the rationale behind each intervention helps patients make informed decisions about their care. In this case, clarifying misconceptions about blowing the nose can empower patients to effectively manage their symptoms and promote recovery.

Correct Answer: A

Rationale: In the context of a patient with COPD, an increased respiratory rate (option A) is indicative of respiratory distress. COPD is a chronic condition characterized by airflow limitation, making it challenging for individuals to breathe effectively. When a patient with COPD experiences respiratory distress, their body compensates by increasing the respiratory rate to enhance oxygen intake and carbon dioxide elimination. This physiological response signifies a worsening of their condition and the need for immediate interventions to support oxygenation. Weak cough effort (option B) is a common manifestation in patients with COPD due to weakened respiratory muscles and impaired airway clearance. However, it is not a direct indicator of acute respiratory distress. Similarly, a barrel-shaped chest (option C) is a chronic finding in COPD resulting from hyperinflation of the lungs over time but does not specifically signify acute distress. Hyperresonance on percussion (option D) is associated with conditions like emphysema, also a component of COPD, but it does not directly indicate acute respiratory distress. Educationally, understanding the signs of respiratory distress in COPD patients is crucial for nurses and healthcare providers. Recognizing these signs promptly can facilitate timely interventions, such as administering supplemental oxygen, initiating bronchodilators, or even escalating care to prevent further deterioration. This knowledge is vital for nursing practice, especially in high-stress environments like emergency departments or critical care units where COPD exacerbations are commonly encountered. By grasping the nuances of COPD management, nurses can deliver effective and timely care, ultimately improving patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) Swish and swallow. When treating an oral fungal infection with nystatin solution, the 'swish and swallow' technique is crucial for the medication to come into contact with all areas of the oral mucosa where the fungal infection may be present. Swishing the solution around the mouth ensures that the medication reaches and treats all affected areas. Swallowing the solution allows for the medication to also target any fungal growth in the esophagus. Option A) Swish and spit is incorrect because spitting out the solution would not allow for the full effectiveness of the medication in treating the fungal infection throughout the oral cavity and esophagus. Option C) Use warm liquids is incorrect as it does not address the proper administration of nystatin solution for oral fungal infections. Option D) Assess for antibiotic allergies is unrelated to the administration of nystatin solution for fungal infections. In an educational context, it is important for nurses and healthcare providers to understand the correct administration techniques for medications to ensure optimal patient outcomes. Proper administration of nystatin solution for oral fungal infections is essential in effectively treating the infection and preventing its spread. By following the 'swish and swallow' technique, healthcare providers can provide appropriate care and support to patients with oral fungal infections.

Correct Answer: A

Rationale: Paradoxical chest movement is a critical sign that can indicate a serious condition like flail chest. Flail chest occurs when a segment of the rib cage is detached from the chest wall, causing paradoxical inward movement during inhalation and outward movement during exhalation. This abnormal movement hinders effective ventilation and can lead to impaired gas exchange, resulting in hypoxemia. Option A, flail chest, is the correct answer because paradoxical chest movement is a classic sign of this condition. It is crucial to recognize this indication promptly to provide appropriate interventions such as stabilizing the chest wall to prevent further respiratory compromise. Option B, chest wall pain, is incorrect because while pain can be associated with flail chest, it is not the defining characteristic. Paradoxical chest movement is a more specific indicator of the underlying structural issue in the chest wall. Option C, elevated pulse rate, is incorrect because although tachycardia can occur in response to hypoxemia, it is not directly related to paradoxical chest movement, which is specific to flail chest. Option D, chest bruising, is incorrect as bruising does not typically cause paradoxical chest movement. It is essential for nursing students to understand the unique signs and symptoms of respiratory conditions like flail chest to provide timely and effective care to patients experiencing respiratory distress. Recognizing paradoxical chest movement in the clinical setting is crucial for prompt intervention and improved patient outcomes.