An hour after a thoracotomy, a patient complains of incisional pain at a level 7 (based on 0 to 10 scale) and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take?

Correct Answer: B

Rationale: In this scenario, the correct action for the nurse to take is to administer the prescribed morphine (Option B). The rationale behind this is that pain management is crucial post-thoracotomy to improve breathing efforts. Severe pain can restrict the patient's ability to take deep breaths, leading to shallow breathing and decreased lung expansion, which can further exacerbate the decreased breath sounds. By administering morphine, the nurse can address the patient's pain, allowing for better breathing efforts and potentially improving lung function. Clamping the chest tube in two places (Option A) is incorrect and dangerous as it can lead to tension pneumothorax, a life-threatening condition. Milking the chest tube (Option C) is not recommended as it can cause clot dislodgement and subsequent blockage of the tube. Assisting the patient with incentive spirometry (Option D) is not the priority in this situation where pain management and addressing the underlying cause of decreased breath sounds are more critical. From an educational perspective, this scenario highlights the importance of prioritizing pain management in postoperative care, especially in thoracic surgeries where adequate breathing is crucial for optimal recovery. Nurses need to understand the implications of severe pain on respiratory function and how appropriate pain control measures can positively impact patient outcomes. This case underscores the significance of critical thinking and prioritization in nursing practice, emphasizing the need to address pain promptly to prevent complications and promote patient well-being.

Correct Answer: B

Rationale: In the context of a patient with an acute exacerbation of COPD, maintaining the pulse oximetry level at 90% or greater (Option B) is the correct approach for determining the appropriate O₂ flow rate. This practice ensures an adequate oxygenation level for the patient while also preventing the risk of suppressing the patient's respiratory drive. Option A is incorrect because minimizing O₂ use to avoid dependency can compromise the patient's oxygenation needs during an acute exacerbation. Option C, administering O₂ based on the patient's level of dyspnea alone, may not guarantee optimal oxygenation. Option D is incorrect as limiting O₂ to 2 L/min may not be sufficient to maintain adequate oxygenation in a patient with a COPD exacerbation. Educationally, understanding the rationale behind the appropriate O₂ flow rate in COPD exacerbation is crucial for nurses to provide safe and effective care. By prioritizing oxygen saturation levels while considering the risk of respiratory drive suppression, nurses can optimize patient outcomes in managing COPD exacerbations. This knowledge helps nurses make informed clinical decisions that align with evidence-based practice guidelines, ensuring patient safety and well-being.

Correct Answer: A

Rationale: The correct answer is A) Obtain O₂ saturation using pulse oximetry because this task involves a direct measurement that does not require interpretation or clinical judgment. Pulse oximetry is a non-invasive procedure that provides immediate feedback on a patient's oxygen saturation levels, which can help in identifying potential respiratory distress or the need for oxygen therapy adjustment. Option B) Monitor for increased O₂ need with exercise involves assessing the patient's response to physical activity, which requires clinical judgment to interpret the findings and decide on appropriate interventions. This task should be performed by a licensed healthcare provider. Option C) Teach the patient about safe use of O₂ at home involves patient education, which requires a comprehensive understanding of the disease process, oxygen therapy guidelines, and potential complications. This task should be carried out by a registered nurse who can provide accurate and individualized information to the patient. Option D) Adjust O₂ to keep saturation in prescribed parameters involves titrating oxygen therapy based on the patient's condition and response, which requires critical thinking skills and clinical judgment. Only a registered nurse or healthcare provider should make decisions regarding oxygen therapy adjustments. In an educational context, it is crucial for nursing students and healthcare professionals to understand the scope of practice for different members of the healthcare team. Delegating tasks appropriately ensures patient safety and quality care delivery. By recognizing the roles and responsibilities of UAP versus registered nurses, we uphold standards of practice and optimize patient outcomes.

Correct Answer: A

Rationale: Because iodine-based contrast media is used during a spiral CT, the patient may need to have the CT scan without contrast or be premedicated before injection of the contrast media. The increased pulse, low oxygen saturation, and tachypnea all indicate a need for further assessment or intervention but do not indicate a need to modify the CT procedure.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Patient with a muffled voice. This patient requires rapid assessment because a muffled voice can be indicative of a peritonsillar abscess. Peritonsillar abscesses can lead to airway compromise and require immediate evaluation and intervention to prevent respiratory distress and potential life-threatening situations. Option B) Patient with a nasal fracture may have pain, swelling, and bleeding but these symptoms do not typically lead to a muffled voice or immediate airway concerns. Option C) Patient with epistaxis (nosebleed) usually presents with bleeding from the nose and does not directly relate to a muffled voice. Option D) Patient with allergic rhinitis may have nasal congestion and sneezing due to allergies but this does not typically cause a muffled voice or require urgent assessment for airway compromise. Educationally, it is important for healthcare providers to recognize the significance of certain symptoms like a muffled voice which can be a red flag for potentially serious conditions. Understanding the urgency of assessing and managing patients based on specific clinical presentations is crucial in providing safe and effective care. This question highlights the importance of prioritizing assessments based on critical symptoms to ensure timely interventions and positive patient outcomes.