The nurse is evaluating and assessing a patient with a diagnosis emphysema. The patient is receiving oxygen at a flow rate of 5 liters by nasal cannula. Which finding concerns the nurse immediately?

Correct Answer: B

Rationale: In this scenario, option B, respiratory rate of 8 breaths/minute, is the most concerning finding for the nurse. A respiratory rate of 8 breaths/minute is abnormally low and may indicate respiratory depression, which can be life-threatening. This finding requires immediate intervention to prevent hypoxia and respiratory failure. Option A, fine bibasilar crackles, is a common finding in patients with emphysema due to air trapping and inflammation in the lungs. While this finding should be monitored, it is not as immediately concerning as a low respiratory rate. Option C, the patient sitting up and leaning over the nightstand, suggests a position that can improve ventilation in patients with respiratory distress. While this position may indicate respiratory distress, it is not as concerning as a low respiratory rate. Option D, a large barrel chest, is a characteristic physical finding in patients with emphysema due to hyperinflation of the lungs. While it indicates a chronic respiratory condition, it is not an acute concern that requires immediate attention. In an educational context, understanding the significance of vital sign abnormalities like respiratory rate is crucial for nurses caring for patients with respiratory conditions. Recognizing abnormal vital signs and their implications allows for prompt intervention and prevention of complications in patients with compromised oxygenation.

Correct Answer: B

Rationale: The correct answer is B) Ensure the mask fits snugly to prevent air leaks. This is the nurse's priority teaching point for a client using a CPAP device for sleep apnea. Proper mask fit is crucial to ensure effective delivery of continuous positive airway pressure, which helps keep the client's airway open during sleep. If the mask does not fit snugly, air leaks can occur, reducing the effectiveness of the therapy and potentially leading to inadequate treatment of sleep apnea. Option A) The device should be used only when symptoms occur is incorrect because CPAP therapy is typically prescribed for nightly use to manage sleep apnea, regardless of symptoms. Option C) Increase the air pressure if breathing becomes difficult is incorrect because changing the air pressure without healthcare provider guidance can be dangerous and should not be done without proper instruction. Option D) Limit use of the device to 4 hours nightly is incorrect because CPAP therapy is typically recommended for continuous use throughout the night to effectively manage sleep apnea. In an educational context, understanding the importance of proper mask fit in CPAP therapy is essential for nurses to effectively teach and support clients with sleep apnea. Ensuring that clients have a clear understanding of how to use and maintain their CPAP devices correctly can significantly improve treatment outcomes and quality of life for individuals with sleep apnea.

Correct Answer: A

Rationale: In the context of carbon monoxide poisoning, the priority action for the nurse is to administer 100% oxygen via a non-rebreather mask (Option A). This is because carbon monoxide has a much higher affinity for hemoglobin than oxygen, leading to tissue hypoxia. By providing high-flow oxygen, the nurse can effectively displace carbon monoxide from hemoglobin and increase the oxygen-carrying capacity of the blood, thereby improving tissue oxygenation. Option B, obtaining a carboxyhemoglobin level, is important for confirming the diagnosis of carbon monoxide poisoning but is not the priority action in an acute situation where immediate intervention is required to improve oxygenation. Option C, placing the client in a hyperbaric oxygen chamber, is a treatment modality for severe cases of carbon monoxide poisoning but may not be readily available or feasible in all healthcare settings. Administering high-flow oxygen is the initial and more practical approach. Option D, initiating continuous pulse oximetry monitoring, is important for ongoing assessment but is not the priority over providing immediate oxygen therapy to address the hypoxia associated with carbon monoxide poisoning. In an educational context, understanding the pathophysiology of carbon monoxide poisoning and the rationale behind the treatment options is crucial for nurses to prioritize interventions effectively in emergency situations. Administering oxygen promptly can be life-saving in cases of carbon monoxide poisoning, making it the priority action for nurses caring for these patients.

Correct Answer: D

Rationale: In this NCLEX-style question on oxygenation, the correct answer is D) 85%. This level indicates significant hypoxemia, which requires immediate nursing intervention to prevent potential harm to the client. Oxygen saturation below 90% is considered a critical level where prompt action is necessary to ensure adequate oxygenation to vital organs. Option A) 94% is within the normal range for oxygen saturation and does not require immediate intervention. Option B) 92% is slightly lower but still generally acceptable in most cases, especially if the client does not have underlying respiratory conditions. Option C) 90% is a borderline level where intervention may be needed depending on the client's condition, but it is not as critical as 85%. Educationally, understanding oxygen saturation levels is crucial for nurses to assess and manage a client's respiratory status effectively. Recognizing when oxygen saturation falls below a certain threshold is essential for early intervention and preventing complications related to hypoxemia. Nurses must be vigilant in monitoring oxygen saturation levels and respond promptly to deviations from the normal range to ensure optimal patient outcomes.

Correct Answer: D

Rationale: In this scenario, the most concerning finding for a client with COPD experiencing an exacerbation is the use of accessory muscles for breathing (Option D). This indicates severe respiratory distress and impending respiratory failure. Option A, a productive cough with yellow sputum, is a common symptom in COPD exacerbations but does not indicate immediate respiratory compromise. Option B, a respiratory rate of 24 breaths per minute, while elevated, may be seen in COPD exacerbations but is not as critical as the use of accessory muscles. Option C, an oxygen saturation of 88%, is low but may be expected in COPD; however, the use of accessory muscles indicates severe respiratory distress. Educationally, understanding these findings is crucial for nurses to prioritize interventions and escalate care appropriately for clients with COPD exacerbations. Recognizing the significance of accessory muscle use can prompt prompt intervention and prevent respiratory failure, highlighting the importance of ongoing assessment and monitoring in respiratory conditions.