The nurse is evaluating and assessing a patient with a diagnosis of 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, the correct answer is option B) Respiratory rate of 8 breaths/minute. Emphysema is a condition characterized by damaged air sacs in the lungs, leading to poor oxygen exchange. A low respiratory rate (bradypnea) can indicate respiratory depression or impending respiratory failure in patients with emphysema. This finding is concerning as it may suggest hypoventilation and inadequate oxygenation despite oxygen therapy. Option A) Fine bibasilar crackles may be expected in patients with emphysema due to underlying lung damage and secretions, but they do not indicate an immediate concern related to oxygen therapy. Option C) The patient sitting up and leaning over the nightstand is a position often assumed by patients with respiratory distress to facilitate breathing and is not an immediate concern. Option D) A large barrel chest is a typical physical characteristic of emphysema and does not raise immediate concern regarding oxygen therapy. Educationally, understanding the rationale behind monitoring respiratory rate in patients receiving oxygen therapy is crucial for nurses caring for patients with respiratory conditions. Recognizing abnormal signs and symptoms promptly can help prevent complications and improve patient outcomes.

Correct Answer: D

Rationale: In this scenario, the most concerning finding among the options provided is option D) The patient's heart rate is 120 beats per minute. This is because an elevated heart rate post-thoracic surgery can be indicative of various complications such as hemorrhage, hypoxia, or cardiac issues, necessitating immediate attention and further assessment. Option A) The patient has 150 mL of bloody drainage in the first hour is a common finding post-thoracic surgery and would require monitoring but is not as acutely concerning as an elevated heart rate. Option B) The patient reports pain at the surgical site is also common postoperatively and can be managed with appropriate pain relief measures, making it a less concerning finding compared to the elevated heart rate. Option C) The patient's chest tube is bubbling intermittently can be a normal finding related to the functioning of the chest tube drainage system and does not necessarily indicate a critical issue requiring immediate intervention. Educationally, understanding the significance of vital sign changes postoperatively is crucial for nurses caring for patients after thoracic surgery. Recognizing abnormal vital sign patterns and prioritizing interventions based on these findings can help prevent complications and improve patient outcomes.

Correct Answer: C

Rationale: In this scenario, the most appropriate intervention is option C: Provide a prescribed cough suppressant for nighttime use. Rationale: 1. Option A: Administering a bronchodilator may help with bronchodilation and improve airflow, but it may not directly address the nighttime cough, which is likely due to irritation and inflammation in the airways caused by acute bronchitis. 2. Option B: Drinking milk before bedtime is unlikely to have a significant impact on reducing nighttime coughing associated with acute bronchitis. It does not address the underlying cause of the cough. 3. Option D: Deep breathing exercises are beneficial for respiratory health, but they may not provide immediate relief from nighttime coughing due to acute bronchitis. Educational Context: Understanding the underlying cause of symptoms is crucial in selecting the appropriate intervention. In the case of acute bronchitis, a prescribed cough suppressant can help alleviate nighttime coughing, allowing the patient to sleep better and promote healing of the airways. It is essential to differentiate between interventions that address symptoms directly and those that may have a more indirect or delayed effect in clinical practice.

Correct Answer: B

Rationale: The correct answer is B) Monitor vital signs and oxygen saturation during the procedure. During a thoracentesis, it is crucial for the nurse to closely monitor the patient's vital signs, including blood pressure, heart rate, and oxygen saturation levels, to detect any signs of complications such as hypoxemia or hypotension promptly. This monitoring ensures the patient's safety and allows for immediate intervention if needed. Option A) Encouraging the patient to lie flat is not recommended during a thoracentesis procedure as it may cause discomfort and increase the risk of complications such as respiratory distress. Option C) Asking the patient to hold their breath as the needle is inserted is incorrect as it can lead to increased tension and anxiety, making the procedure more challenging for the patient and healthcare provider. Option D) Administering sedatives to keep the patient calm and still is not the most appropriate intervention during a thoracentesis as sedation can impact the patient's ability to communicate any discomfort or complications during the procedure. In an educational context, understanding the importance of close monitoring and assessment during invasive procedures like thoracentesis is essential for nurses to provide safe and effective care to patients. Emphasizing the significance of vigilant monitoring helps nurses develop critical thinking skills and clinical judgment in managing patients undergoing such procedures.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) A patient with asthma whose peak flow is 50% of their personal best. This patient should be assessed first because a peak flow of 50% indicates a significant decline in respiratory function and potential impending respiratory distress or exacerbation. As asthma is a condition characterized by reversible airway obstruction, prompt assessment and intervention are crucial to prevent severe complications like respiratory failure. Option A) is incorrect because mild fatigue in a patient with emphysema, while concerning, does not indicate an immediate decline in respiratory status. Option B) is also incorrect as thick, yellow sputum in a patient with bronchitis suggests a bacterial infection but does not necessarily require immediate assessment compared to compromised respiratory function in an asthmatic patient. Option D) is incorrect as occasional dizziness in a patient with COPD, while important to monitor, does not pose an immediate threat to respiratory function as a significant drop in peak flow does in asthma. In an educational context, this question highlights the importance of prioritizing patient assessments based on the urgency of the situation and the potential impact on the patient's health. Understanding the specific indicators of respiratory distress in different chronic respiratory illnesses is crucial for nurses to provide timely and effective care to their patients.