The nurse is caring for a hospitalized older patient who has nasal packing in place after a nosebleed. Which assessment finding will require the most immediate action by the nurse?

Correct Answer: A

Rationale: In this scenario, option A is the correct answer because an oxygen saturation level of 89% indicates hypoxemia, which is a critical condition requiring immediate intervention to optimize oxygenation and prevent further complications such as tissue damage, organ dysfunction, or even cardiac arrest. As the nurse's priority is to ensure adequate oxygenation for the patient's well-being, addressing hypoxemia takes precedence over other assessment findings. Options B, C, and D are incorrect in this context. Option B, the red and swollen nose, is a common and expected finding in a patient with nasal packing after a nosebleed and does not pose an immediate threat to the patient's health. Option C, the patient's pain level, while important for overall patient care, does not take precedence over the critical issue of hypoxemia. Option D, a temperature of 100.1°F, may indicate a mild fever but is not as urgent as addressing hypoxemia. Educationally, this question highlights the importance of prioritizing patient assessments based on the severity of the condition. It emphasizes the need for nurses to quickly recognize and address life-threatening situations such as hypoxemia to ensure patient safety and well-being. Understanding the significance of oxygen saturation levels and their impact on overall patient health is crucial for nurses in various clinical settings.

Correct Answer: A

Rationale: Rationale: The correct action for the nurse to take next is option A, which is to auscultate for breath sounds. This is the most appropriate initial step in assessing the patient's complaint of sharp pain upon deep breathing. Auscultating breath sounds can help the nurse identify any abnormal findings such as decreased or absent breath sounds that could indicate underlying issues like a pneumothorax or pleural effusion. By listening to the breath sounds, the nurse can gather crucial information to guide further assessment and management of the patient's condition. Option B, administering PRN morphine, is not the immediate priority in this scenario. While pain management is important, it is essential to first assess the underlying cause of the pain before administering analgesics. Option C, having the patient cough forcefully, may exacerbate the pain and is not indicated without a comprehensive assessment. Option D, notifying the patient's health care provider, can be considered after the initial assessment of breath sounds to report findings and collaborate on the patient's care plan. Educational Context: Understanding the importance of assessing breath sounds in a patient complaining of chest pain is crucial for nurses caring for patients with respiratory conditions like pneumonia. Auscultation is a fundamental nursing skill that helps in identifying respiratory abnormalities and guiding appropriate interventions. By prioritizing the assessment of breath sounds, nurses can promptly recognize potential complications and provide timely and effective care to improve patient outcomes. This case highlights the significance of systematic assessment and critical thinking in nursing practice to deliver safe and quality patient care.

Correct Answer: C

Rationale: In caring for a patient with cor pulmonale, monitoring for peripheral edema is crucial as it is a common expected finding due to fluid retention in right heart failure caused by lung disease. The correct answer, option C, is indicative of the pathophysiology of cor pulmonale, where the right side of the heart is unable to effectively pump blood to the lungs, leading to fluid accumulation in the body, particularly in the extremities. Option A, chest pain, is less likely in cor pulmonale unless there are complications like pulmonary embolism. Option B, finger clubbing, is associated with chronic hypoxia and conditions like cystic fibrosis, not specifically cor pulmonale. Option D, elevated temperature, is not a typical finding in cor pulmonale unless there is an underlying infection. In an educational context, understanding the signs and symptoms of cor pulmonale is vital for nurses caring for patients with respiratory conditions. Recognizing peripheral edema as a key indicator helps in early identification and appropriate management of this serious complication. This knowledge enhances nursing assessment skills and improves patient outcomes by facilitating timely interventions to address fluid overload in cor pulmonale.

Correct Answer: A

Rationale: The correct answer is A) pH 7.28, PaCO₂ 50 mm Hg, and PaO₂ 58 mm Hg. This patient's arterial blood gas results indicate respiratory acidosis (low pH) and hypoxemia (low PaO₂). Respiratory acidosis can lead to serious complications like respiratory failure and cardiac arrhythmias. Therefore, prompt intervention is crucial in this case to improve oxygenation and correct acidosis. Option B) pH 7.48, PaCO₂ 30 mm Hg, and PaO₂ 65 mm Hg indicates respiratory alkalosis with mild hypoxemia, which may not require immediate intervention. Option C) pH 7.34, PaCO₂ 33 mm Hg, and PaO₂ 80 mm Hg shows normal pH with normal PaO₂ levels, indicating adequate oxygenation and ventilation. Option D) pH 7.31, PaCO₂ 58 mm Hg, and PaO₂ 64 mm Hg suggests respiratory acidosis with hypercapnia but better oxygenation compared to option A. While intervention is needed, it may not be as urgent as in option A. Educationally, understanding arterial blood gas results is crucial for nurses to assess and manage patients with respiratory conditions effectively. Recognizing abnormal values and knowing when to intervene promptly can prevent further deterioration and improve patient outcomes.

Correct Answer: D

Rationale: The correct answer is D) Contact a health care provider. This option is correct because an increased need for a rapid-acting bronchodilator indicates that the patient's respiratory condition may be worsening or that their current treatment regimen is not providing adequate relief. In such a situation, it is crucial for the patient to seek medical advice promptly to prevent a potential acute exacerbation of their condition. Option A) Increase fluid intake is incorrect because while staying hydrated is important for overall health, it is not the appropriate action to take in response to an increased need for a bronchodilator. Option B) Monitor oxygen saturation is also incorrect as simply monitoring oxygen levels without taking any further action may delay necessary medical intervention if the patient's condition deteriorates. Option C) Continue current therapy is incorrect because if the patient is experiencing an increased need for a rapid-acting bronchodilator, it suggests that their current therapy may not be sufficient, and simply continuing with the same treatment may lead to worsening symptoms. In an educational context, it is important to teach patients how to recognize changes in their symptoms and when to seek medical assistance. Understanding when to contact a healthcare provider can be crucial in managing chronic respiratory conditions effectively and preventing serious complications. Encouraging patients to be proactive about their health and seek timely medical advice when needed can lead to better outcomes and improved quality of life.