The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?

Correct Answer: D

Rationale: The correct answer is D. A PaO2 level of 59 mm Hg indicates severe hypoxemia, which requires immediate action to ensure adequate oxygen delivery to tissues. Normal PaO2 levels are typically above 80 mm Hg. Low PaO2 can lead to tissue hypoxia and is a critical finding that needs prompt intervention. Choice A (HCO3– of 31 mEq/L) is slightly elevated but does not require immediate action. Choice B (SaO2 of 92%) is within the normal range and does not indicate an urgent issue. Choice C (PaCO2 of 31 mm Hg) is also within the normal range and does not necessitate immediate intervention. In summary, the correct answer is D because a low PaO2 level signifies severe hypoxemia, requiring prompt attention to prevent potential complications.

Correct Answer: C

Rationale: The correct answer is C because salmeterol is a long-acting beta agonist used for maintenance treatment of asthma, not for acute attacks. Daily use helps prevent asthma symptoms by providing long-term bronchodilation. Choices A and B are incorrect as salmeterol is not for acute attacks or require food with it. Choice D is not necessary for salmeterol, as it does not typically affect pulse rate significantly.

Correct Answer: B

Rationale: The correct answer is B. A heart rate of 112 bpm is concerning in a patient taking theophylline because it can indicate theophylline toxicity, which can lead to serious cardiac arrhythmias. Theophylline has a narrow therapeutic index, and levels above 20 mcg/mL can be toxic. Nausea, vomiting, and mild hand tremors are common side effects of theophylline but are not typically indicative of toxicity. Monitoring the theophylline level is important, but a level of 15 mcg/mL alone does not indicate toxicity. In summary, the elevated heart rate is the most concerning finding as it suggests potential theophylline toxicity, while the other options are more commonly seen as side effects without indicating toxicity.

Correct Answer: C

Rationale: Correct Answer: C Rationale: 1. The patient statement "I can drive myself home after the procedure" indicates a lack of understanding of the sedative effects of the procedure. 2. Sedation is commonly used during bronchoscopy, impairing the patient's ability to drive safely. 3. Patients should arrange for someone to drive them home post-procedure to ensure their safety and comply with medical guidelines. Summary: A: Correct - Fasting before bronchoscopy is necessary to reduce the risk of aspiration. B: Incorrect - Throat discomfort is a common post-procedure symptom. D: Incorrect - Allergies to anesthesia should be reported for safety reasons.

Correct Answer: A

Rationale: The correct answer is A: Encourage the patient to drink at least 2 liters of water daily. This intervention promotes hydration, which helps to liquefy thick respiratory secretions, making them easier to expectorate. Drinking adequate water also maintains mucous membrane hydration. Option B (mucolytics) may be prescribed but may not be as effective without sufficient hydration. Option C (suctioning) is invasive and should be done cautiously to prevent mucosal damage. Option D (chest physiotherapy) helps with secretion mobilization but may not be as directly effective as hydration in liquefying secretions. In summary, promoting hydration is the most effective and least invasive intervention for a patient with thick respiratory secretions.