The nurse is caring for a patient with acute respiratory distress. What assessment finding is the priority to report?

Correct Answer: A

Rationale: The correct answer is A: Oxygen saturation of 86% on room air. This is the priority finding to report because it indicates severe hypoxemia, which is a life-threatening condition requiring immediate intervention to prevent tissue damage and organ failure. Oxygen saturation should ideally be above 90%. Choice B (Respiratory rate of 28 breaths per minute) is important but not as critical as severe hypoxemia. Choice C (Heart rate of 102 beats per minute) may be a compensatory response to hypoxemia, and while important, it is not as urgent as addressing the low oxygen saturation. Choice D (Blood pressure of 140/92 mm Hg) is within normal range and does not indicate immediate danger compared to severe hypoxemia.

Correct Answer: A

Rationale: The correct answer is A: Administer supplemental oxygen. In a patient with heart failure experiencing shortness of breath, the priority intervention is to improve oxygenation. Supplemental oxygen helps increase oxygen levels and alleviate respiratory distress. This is crucial to prevent further deterioration and potential complications. Administering a diuretic (B) would help with fluid overload but does not address the immediate need for oxygen. Administering an IV analgesic (C) is not indicated for shortness of breath in heart failure. Administering a vasodilator (D) may worsen the condition by decreasing blood pressure and cardiac output.

Correct Answer: B

Rationale: The correct answer is B, administer rifampin. The priority in caring for a patient with TB is to start anti-TB medications promptly to prevent the spread of the infection. Rifampin is one of the first-line drugs used to treat TB. Administering a PPD test (A) is important for diagnosis but not the priority at this moment. Administering an injectable antihistamine (C) is not indicated for TB treatment. Administering oxygen therapy (D) may be necessary based on the patient's condition but treating the underlying infection with rifampin takes precedence.

Correct Answer: C

Rationale: The correct answer is C: How long has it been since you moved to the United States? This question is important because TB prevalence varies in different countries, and individuals who have recently immigrated from high TB burden countries may have a higher risk of TB infection. It helps the nurse assess the individual's potential exposure risk. A: Do you take any over-the-counter (OTC) medications? - This question is not directly related to TB skin testing and does not provide information relevant to assessing TB risk. B: Do you have any family members with a history of TB? - While a family history of TB can be a risk factor, it is not as directly relevant as the timing of immigration in this context. D: Did you receive the bacille Calmette-Guérin (BCG) vaccine for TB? - While BCG vaccination history is important for interpreting TB skin test results, it is not as crucial as determining recent immigration status when assessing TB risk.

Correct Answer: D

Rationale: The correct answer is A: Encourage early ambulation. This is the priority intervention to prevent DVT because it promotes blood circulation and prevents stasis in the veins. - Option B: Administer a platelet aggregation inhibitor is incorrect as it is not the first-line intervention for preventing DVT. - Option C: Administer anticoagulants may be used in some cases, but it is not the priority intervention. - Option D: Monitor the patient's oxygen saturation levels is not directly related to preventing DVT and is not the priority intervention.