The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the past 3 days. Which finding is important for the nurse to report to the health care provider?

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Respirations are 36 breaths/min. This finding is crucial to report to the healthcare provider because an increased respiratory rate (tachypnea) in a patient with COPD experiencing worsening dyspnea could indicate respiratory distress or impending respiratory failure. This rapid breathing may be a compensatory mechanism to maintain oxygen levels, suggesting the need for immediate intervention or adjustment of oxygen therapy. Option B) Anterior-posterior chest ratio is 1:1 is incorrect as it describes a normal chest shape and does not provide relevant information regarding the patient's respiratory status. Option C) Lung expansion is decreased bilaterally could be expected in a patient with COPD due to air trapping and hyperinflation, so it is not as urgent to report compared to the elevated respiratory rate. Option D) Hyperresonance to percussion is present is a typical finding in COPD due to increased air in the lungs, not requiring immediate reporting compared to the high respiratory rate. Educationally, this question highlights the importance of recognizing subtle changes in respiratory status in patients with COPD, emphasizing the significance of monitoring respiratory rate as a vital sign and understanding its implications in managing oxygen therapy for these patients effectively. It underscores the need for prompt reporting of concerning signs and symptoms to prevent respiratory decompensation and improve patient outcomes.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Paradoxical chest movement. Paradoxical chest movement occurs when a segment of the chest wall moves in the opposite direction to the rest of the chest during breathing. This finding indicates a serious underlying issue, such as a flail chest, which can impair ventilation and lead to respiratory distress. Option B) Complaint of chest wall pain is a common and expected finding in a patient with a chest wall contusion. It is a typical symptom that would be present due to the injury sustained and does not raise immediate concern regarding the patient's respiratory status. Option C) Heart rate of 110 beats/minute can be a normal physiological response to pain, anxiety, or stress. While it is essential to monitor, it is not as concerning as paradoxical chest movement, which directly impacts the patient's ability to breathe effectively. Option D) Large bruised area on the chest is also an expected finding in a patient with a chest wall contusion and does not necessarily indicate a critical issue with the patient's respiratory status. From an educational perspective, understanding the significance of paradoxical chest movement in the context of chest trauma is crucial for healthcare providers, especially in emergency situations. Recognizing this finding promptly can help initiate appropriate interventions to prevent further respiratory compromise and improve patient outcomes. It highlights the importance of thorough assessment and clinical judgment in identifying potentially life-threatening conditions.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Placing the patient on droplet precautions in a private hospital room. This action indicates a need for further teaching because pulmonary fungal infections are not transmitted through droplets; they are typically spread through spores in the environment. Placing the patient on droplet precautions is unnecessary and does not align with evidence-based practice for this type of infection. Option A is correct as listening to lung sounds is a crucial nursing intervention to assess the patient's respiratory status, especially in dyspnea cases. Option C is also appropriate as monitoring serology results can help identify the specific fungal organism causing the infection, guiding treatment decisions. Option D is incorrect because increasing the oxygen flow rate to maintain oxygen saturation above 90% is a standard intervention for patients with dyspnea and respiratory distress, regardless of the cause. It is essential for providing adequate oxygenation to the patient. In an educational context, understanding the rationale behind each action is crucial for providing safe and effective patient care. Nurses need to be knowledgeable about the appropriate precautions for different infectious diseases and understand the principles of oxygen therapy to optimize patient outcomes. This scenario highlights the importance of evidence-based practice and critical thinking in nursing care.

Correct Answer: B

Rationale: The correct answer is B) Keep the air entrainment ports clean and unobstructed. Rationale: Maintaining clean and unobstructed air entrainment ports is crucial when a patient is receiving oxygen therapy via a Venturi mask. The Venturi mask delivers a specific concentration of oxygen by mixing oxygen with room air through these ports. If the ports are dirty or blocked, the accurate oxygen concentration may not be delivered, potentially compromising the patient's oxygenation. Option A is incorrect because patients should remove the mask during meals to facilitate eating and prevent aspiration. Option C is incorrect because the flow rate on a Venturi mask is predetermined to deliver a specific oxygen concentration, and adjusting the flow rate to prevent bag collapse can alter the oxygen delivery. Option D is incorrect as draining moisture condensation from tubing is important for preventing infection or discomfort but does not directly impact oxygen delivery. Educational Context: Nurses must understand the principles of oxygen therapy delivery methods to ensure safe and effective patient care. Keeping air entrainment ports clean and unobstructed is essential for accurate oxygen delivery and patient safety when using a Venturi mask. Nurses should educate patients on proper mask use and maintenance to optimize therapeutic outcomes.

Correct Answer: B

Rationale: In the scenario of a patient experiencing an acute asthma attack, the nurse should administer Albuterol (Ventolin HFA) 2.5 mg per nebulizer first. Albuterol is a short-acting beta agonist bronchodilator that works quickly to open up the airways, providing immediate relief during an asthma exacerbation. It helps to relieve bronchospasm and improve airflow. Methylprednisolone (Solu-Medrol) 60 mg IV (Option A) is a corticosteroid used for its anti-inflammatory effects in asthma, but it works more slowly and is typically given after the bronchodilator to address inflammation. Salmeterol (Serevent) 50 mcg per dry-powder inhaler (DPI) (Option C) is a long-acting beta agonist used for maintenance therapy in asthma, not for immediate relief during an acute attack. Ipratropium (Atrovent) 2 puffs per metered-dose inhaler (MDI) (Option D) is an anticholinergic bronchodilator that can be used in conjunction with a beta agonist like Albuterol, but it is not the initial drug of choice for acute asthma exacerbations. Educationally, understanding the appropriate sequence of medications in managing asthma exacerbations is crucial for nurses to provide timely and effective care to patients in respiratory distress. Knowing the mechanism of action and indications for each medication option helps nurses make informed decisions in emergency situations.