The nurse is caring for a client with pulmonary embolism (PE). Which clinical sign is most concerning?

Correct Answer: D

Rationale: The correct answer is D because a low oxygen saturation level of 85% indicates poor oxygen exchange in the lungs, which can be life-threatening in a PE. Step 1: Oxygen saturation is a direct measure of how well the lungs are oxygenating the blood, making it a critical parameter in PE. Step 2: A low oxygen saturation level can lead to tissue hypoxia and organ dysfunction. Step 3: Prompt intervention is necessary to improve oxygenation and prevent further complications. Choices A, B, and C are important but not as immediately concerning as a low oxygen saturation level in a client with PE.

Correct Answer: B

Rationale: The correct answer is B because a chest tube dressing saturated with blood indicates active bleeding, which can lead to complications like hemorrhage or tension pneumothorax. Immediate intervention is needed to prevent further issues. A: Serosanguinous drainage is expected initially after chest tube insertion. C: Intermittent bubbling in the water seal chamber is normal and indicates proper functioning. D: Chest tube secured with tape and sutures is appropriate for stabilization.

Correct Answer: C

Rationale: The correct answer is C: Shortness of breath at rest. This symptom is concerning as it indicates severe respiratory distress, potentially leading to respiratory failure. Shortness of breath at rest is a red flag for worsening bronchitis or complications like pneumonia. A: Persistent productive cough is common in bronchitis and may indicate ongoing inflammation or infection. It is not as immediately concerning as shortness of breath at rest. B: Yellow-green sputum suggests a bacterial infection, but it is not as urgent as shortness of breath at rest. D: Low-grade fever is a common symptom of bronchitis and may not indicate a severe condition unless it persists or worsens.

Correct Answer: B

Rationale: Step 1: Guaifenesin is an expectorant that works by thinning mucus in the airways. Step 2: Thinning mucus helps to make it easier for the client to cough up and clear the mucus. Step 3: This promotes expectoration, which helps to relieve congestion and improve breathing. Step 4: Therefore, the primary purpose of guaifenesin is to thin mucus and promote expectoration in clients with bronchitis.

Correct Answer: B

Rationale: The correct answer is B because yellowing of the skin or eyes can indicate liver toxicity, a serious side effect of isoniazid. Reporting this symptom promptly can prevent further complications. Choice A is incorrect because vitamin C does not interfere with isoniazid therapy. Choice C is incorrect as stopping medication prematurely can lead to drug resistance. Choice D is incorrect as antacids can reduce the effectiveness of isoniazid.