The nurse assesses a patient with a chest tube and notes subcutaneous emphysema. What is the appropriate action?

Correct Answer: B

Rationale: The correct answer is B: Document the finding and continue monitoring. Subcutaneous emphysema in a patient with a chest tube indicates air leakage but does not require immediate intervention. Clamping the chest tube could lead to tension pneumothorax. Notifying the healthcare provider is important but not urgent unless other symptoms are present. Replacing the chest tube drainage system is not necessary at this point. Regular monitoring and documentation allow for appropriate intervention if the condition worsens.

Correct Answer: B

Rationale: The correct answer is B because an oxygen saturation of 89% indicates severe hypoxemia, which can be life-threatening and requires immediate intervention to prevent tissue damage or organ failure. Oxygen is essential for cellular metabolism, and a saturation below 90% can lead to serious complications. A: Drainage of 150 mL in the first hour is within the expected range post-lobectomy and does not require immediate action. C: Mild incisional pain is a common finding post-surgery and can be managed with appropriate pain medication; it does not necessitate immediate action. D: Absent air leak in the chest tube is a desired outcome post-lobectomy, indicating proper lung re-expansion and no immediate intervention is needed in this case.

Correct Answer: D

Rationale: The correct answer is D. Secondhand smoke can contribute to lung diseases in adults and children through various mechanisms. Firstly, it can increase mucus production, leading to airway obstruction and difficulty breathing. Secondly, it can cause developmental delays in children due to the harmful effects on their respiratory and overall health. Lastly, it impairs epithelium maturation, affecting the lining of the respiratory tract and making individuals more susceptible to infections and respiratory diseases. Therefore, all of the above choices are correct in explaining how secondhand smoke contributes to lung diseases.

Correct Answer: C

Rationale: The priority nursing intervention for a patient with COPD is to encourage the patient to rest (Choice C). This is because in COPD, the patient often experiences difficulty breathing, leading to increased work of breathing and fatigue. Rest allows the patient to conserve energy, reduce oxygen demand, and prevent exacerbation of symptoms. Encouraging deep breathing exercises (Choice A) may be beneficial for lung expansion but can also increase the work of breathing and lead to fatigue. While fluid intake (Choice B) is important for overall health, it is not the priority in managing acute COPD exacerbation. Using a peak flow meter (Choice D) is more relevant for monitoring asthma rather than COPD. Thus, the correct answer is C as it addresses the immediate need to reduce the patient's respiratory workload and promote recovery.

Correct Answer: C

Rationale: The correct answer is C: Assess for signs of hypoglycemia. This is the first step because hypoglycemia can mimic stroke symptoms and must be ruled out before proceeding with any other assessments or interventions. Treating hypoglycemia promptly is crucial to prevent further complications. Assessing the patient's neurological status (choice A) and performing a neurological exam (choice B) can be done after ruling out hypoglycemia. Administering thrombolytic therapy (choice D) is not appropriate without a proper assessment and diagnosis.