The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patient's lungs, which finding would the nurse most likely hear?

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Discontinuous, high-pitched sounds of short duration during inspiration. This finding indicates crackles, which are commonly heard in patients with heart failure due to fluid accumulation in the lungs. Crackles are caused by the sudden opening of small airways and alveoli that are filled with fluid. Option A, continuous rumbling, snoring, or rattling sounds mainly on expiration, describes rhonchi, which are more commonly associated with conditions like pneumonia or bronchitis. Option B, continuous high-pitched musical sounds on inspiration and expiration, describes wheezes, typically heard in conditions such as asthma or chronic obstructive pulmonary disease (COPD). Option D, a series of long-duration, discontinuous, low-pitched sounds during inspiration, describes wheezes as well, which are not typically associated with heart failure. Educationally, understanding lung auscultation findings is crucial for nurses to assess and manage patients effectively. Recognizing the differences between crackles, rhonchi, and wheezes can guide appropriate interventions and treatment plans for patients with varying respiratory conditions. Mastering these auscultation skills enhances the nurse's ability to provide high-quality care and improve patient outcomes.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D) Sputum smears for acid-fast bacilli are negative. This finding is crucial when considering discontinuing airborne precautions for a patient with active tuberculosis. A negative sputum smear indicates a lower risk of transmitting the disease to others through the air, thus justifying the discontinuation of airborne precautions. Option A) Chest x-ray showing no upper lobe infiltrates does not directly relate to the infectiousness of the patient. TB medications being taken for 6 months (option B) is important for treatment but does not determine the need for airborne precautions. Mantoux testing showing an induration of 10 mm (option C) indicates exposure to TB but does not confirm active infection or infectiousness. In an educational context, understanding the criteria for discontinuing airborne precautions in patients with active TB is vital for healthcare providers to prevent the spread of the disease. Negative sputum smears are a key indicator in this decision-making process, as they reflect the presence or absence of infectious bacilli in the respiratory secretions. Healthcare professionals must interpret these findings accurately to ensure appropriate infection control measures are implemented.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Acetaminophen (Tylenol). The rationale behind this choice is that acetaminophen is indicated for reducing fever and alleviating pain, which are the immediate concerns for the patient with a high fever and severe pleuritic chest pain. It helps in improving the patient's comfort and reducing the inflammatory response associated with pneumonia. Option A) Codeine is a narcotic antitussive used for cough suppression, but in this case, the priority is to address the fever and pain. Option B) Guaifenesin is an expectorant used to promote the clearance of mucus but does not address the patient's immediate symptoms. Option D) Piperacillin/tazobactam (Zosyn) is an antibiotic used to treat bacterial infections, but it is not the first-line intervention for symptomatic relief in this scenario. Educationally, it is crucial for nurses to prioritize interventions based on the patient's presenting symptoms and immediate needs. Understanding the rationale behind each medication choice helps nurses provide effective and evidence-based care to improve patient outcomes in various clinical situations.

Correct Answer: B

Rationale: In this scenario, option B, "O₂ saturation is >90%," is the best indicator that the therapy for the patient with asthma has been effective. Oxygen saturation levels reflect the amount of oxygen bound to hemoglobin in the blood, indicating the efficiency of oxygen delivery to tissues. In asthma, ensuring adequate oxygenation is crucial to prevent hypoxia and tissue damage. An O₂ saturation level above 90% indicates sufficient oxygen is reaching the tissues, reflecting the effectiveness of the therapy. Option A, "No wheezes are audible," is not the most reliable indicator of therapy effectiveness as wheezes can persist even with improved oxygenation. Wheezes are caused by narrowed airways and may not disappear immediately after treatment. Option C, "Accessory muscle use has decreased," is a good indicator of respiratory distress relief; however, it may persist for some time even after oxygenation has improved, making it less immediate than oxygen saturation levels. Option D, "Respiratory rate is 16 breaths/minute," is a general indicator of respiratory status but may not always reflect the effectiveness of oxygen therapy specifically. A normal respiratory rate does not guarantee adequate oxygenation. In an educational context, understanding these assessment parameters is crucial for nurses managing patients with respiratory conditions like asthma. It highlights the importance of comprehensive assessment and the significance of oxygen saturation levels in evaluating the response to therapy and ensuring optimal patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) "I can have ice cream as a snack every day." This statement indicates effective teaching because patients with COPD and low BMI often struggle to maintain adequate caloric intake due to increased energy expenditure from labored breathing. Ice cream, being a high-calorie, high-fat food, can help boost calorie intake and aid in weight gain for these patients. Option A is incorrect as increasing fluid intake with meals does not directly address the need for increased caloric intake. Option C, while promoting exercise, does not specifically address the issue of low BMI in COPD patients. Option D, decreasing meat and poultry intake, is not ideal as these protein-rich foods can be beneficial for maintaining muscle mass in COPD patients. In an educational context, it is crucial for nurses to provide dietary teaching that is tailored to the specific needs of patients with COPD. Understanding the relationship between low BMI and COPD, and recognizing the importance of calorie-dense foods in their diet, can significantly impact the health outcomes of these patients. Effective teaching empowers patients to make informed decisions about their dietary choices to improve their overall well-being.