The nurse is assessing a patient with chronic bronchitis who reports increased fatigue and productive cough. What finding requires immediate action?

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Oxygen saturation of 89%. This finding requires immediate action because a saturation level below 90% indicates severe hypoxemia, which can lead to serious complications such as organ damage or respiratory failure. Oxygen saturation is a critical parameter to assess the adequacy of oxygenation in patients with respiratory conditions like chronic bronchitis. Option B) Productive cough with green sputum is a common symptom of chronic bronchitis and, although it may indicate an infection, it does not require immediate action as the change in sputum color alone is not an emergency. Option C) Heart rate of 92 beats per minute is within the normal range for many adults and, while it should be monitored, it does not indicate an immediate need for intervention in this context. Option D) Increased sputum production is also a common symptom in chronic bronchitis and does not necessitate immediate action unless accompanied by other concerning symptoms. Educationally, this question highlights the importance of prioritizing assessments based on the urgency of the patient's condition. Understanding the significance of oxygen saturation levels in respiratory disorders is crucial for nurses to intervene promptly and prevent potential complications.

Correct Answer: C

Rationale: In the context of a patient with chronic bronchitis, a respiratory rate of 28 breaths per minute is a priority finding to report to the provider because it indicates respiratory distress and potential respiratory failure. This high respiratory rate may suggest inadequate oxygenation, increased work of breathing, and impending respiratory arrest. Prompt intervention is crucial to prevent further deterioration in the patient's condition. Option A: The presence of bilateral ankle edema is concerning for fluid retention, which may be related to heart failure or renal issues. While important, it is not the most immediate concern in a patient with chronic bronchitis. Option B: Green and thick sputum may indicate a bacterial infection, but it is not as urgent as the respiratory distress indicated by a high respiratory rate. Option D: An oxygen saturation of 91% is low and requires monitoring and intervention, but a high respiratory rate takes precedence as it indicates immediate respiratory compromise. In an educational context, understanding the priority of findings in patients with respiratory conditions is crucial for nurses to provide timely and appropriate care. Recognizing signs of respiratory distress and knowing when to escalate care are essential skills for nurses caring for patients with respiratory conditions like chronic bronchitis.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Explain that this is a normal side effect of the medication. This response is correct because the orange discoloration of bodily fluids is a known side effect of the medication used to treat tuberculosis, specifically rifampin. It is important for the nurse to educate the patient about this side effect to alleviate any concerns and ensure medication adherence. Option A) Discontinuing the medication immediately is not necessary in this case because the orange discoloration is not a sign of a serious adverse reaction requiring immediate cessation of treatment. Option B) Reporting the finding to the healthcare provider may not be needed as this side effect is well-documented and does not typically require medical intervention. Option D) Checking for signs of an allergic reaction is not warranted as the orange discoloration is a known non-allergic side effect of the medication. Educationally, this question highlights the importance of understanding common side effects of medications used in the treatment of tuberculosis. Nurses need to be knowledgeable about medication side effects to provide accurate information and support to patients undergoing treatment. It also emphasizes the need for patient education to address concerns and promote medication adherence.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Decreased use of accessory muscles during exhalation. Pursed-lip breathing is a technique commonly used to improve breathing efficiency in patients with COPD by prolonging exhalation, preventing airway collapse, and promoting better gas exchange. When a patient with COPD effectively uses pursed-lip breathing, they experience decreased respiratory effort and reduced reliance on accessory muscles to breathe, leading to improved ventilation and oxygenation. Option B) Increased respiratory rate to 22 breaths per minute is incorrect because an increased respiratory rate may indicate respiratory distress or inadequate gas exchange, which is not a sign of improved breathing in this context. Option C) Oxygen saturation remaining at 88% is incorrect because although oxygen saturation is an important parameter to monitor in COPD patients, it alone does not indicate the effectiveness of pursed-lip breathing. Oxygen saturation may remain the same even if breathing efficiency has improved. Option D) Improved breath sounds bilaterally is incorrect because while improved breath sounds can be a positive sign, they do not directly indicate the effectiveness of pursed-lip breathing in a patient with COPD. It is more important to focus on the patient's respiratory effort and use of accessory muscles to assess the impact of the breathing technique. In an educational context, understanding the rationale behind the correct answer reinforces the importance of therapeutic breathing techniques like pursed-lip breathing in managing COPD. It highlights the goal of reducing respiratory work and improving gas exchange in these patients. Additionally, differentiating between the options helps students develop critical thinking skills and clinical reasoning abilities when evaluating patient responses to interventions.

Correct Answer: B

Rationale: In the context of caring for a patient with suspected pneumonia, the most appropriate initial diagnostic test to perform is a chest x-ray (option B). This is because a chest x-ray can provide quick and valuable information about the presence of infiltrates, consolidation, or other abnormalities in the lungs that are indicative of pneumonia. Identifying these findings promptly can guide timely treatment decisions and help in monitoring the progression of the disease. Regarding the other options: A) Complete blood count (CBC) may provide information about white blood cell counts, which can be elevated in the presence of infection, but it does not directly visualize lung abnormalities. C) Arterial blood gas (ABG) analysis can assess oxygenation and acid-base status but is not the primary test for diagnosing pneumonia. D) Sputum culture is important for identifying the specific pathogen causing pneumonia but is usually not the initial test performed. In an educational context, understanding the rationale behind selecting the most appropriate diagnostic test is crucial for nursing practice. It helps students develop critical thinking skills to prioritize care, make sound clinical judgments, and provide evidence-based interventions. By grasping the significance of diagnostic tests in specific clinical scenarios, nurses can enhance patient outcomes through accurate and timely diagnosis and treatment.