The nurse is monitoring a client receiving oxygen therapy at 4 L/min via nasal cannula. Which finding requires immediate action?

Correct Answer: B

Rationale: In this scenario, option B, "Restlessness and confusion," requires immediate action because it suggests a potential oxygen saturation issue despite the oxygen therapy being administered. Restlessness and confusion can indicate hypoxia, a serious condition where the body is not receiving enough oxygen. This finding could be an early sign of respiratory distress and requires prompt assessment and intervention to prevent further deterioration. Option A, "Dry nasal mucosa," is a common side effect of oxygen therapy and can be managed with humidification. While uncomfortable, it does not pose an immediate threat to the client's health. Option C, "Decreased respiratory rate to 12 breaths/min," could be concerning if accompanied by other symptoms of respiratory distress. However, a respiratory rate of 12 breaths/min within a normal range does not necessarily indicate a critical issue in isolation. Option D, "Oxygen saturation of 96%," is within the normal range for oxygen saturation and indicates adequate oxygenation. While continuous monitoring is essential, a saturation of 96% does not require immediate action unless there are other concerning symptoms present. Educationally, this question highlights the importance of recognizing early signs of hypoxia in clients receiving oxygen therapy. It emphasizes the need for nurses to prioritize critical thinking and prompt assessment to ensure the safety and well-being of their clients. By understanding the significance of different clinical findings, nurses can provide timely interventions and prevent potential complications in their practice.

Correct Answer: B

Rationale: In assessing a client with suspected pneumothorax, the finding most indicative of this condition is decreased breath sounds on the affected side (Option B). This is because a pneumothorax involves air accumulating in the pleural space, causing lung collapse. As a result, breath sounds are diminished or absent over the affected area. Option A, dullness on percussion, is associated with conditions like pleural effusion, not pneumothorax. Option C, barrel-shaped chest, is typically seen in patients with chronic obstructive pulmonary disease (COPD). Option D, cyanosis of lips and fingertips, is a sign of hypoxia and is not specific to pneumothorax. In an educational context, understanding the specific clinical manifestations of pneumothorax is crucial for nurses to provide timely and accurate care. Recognizing decreased breath sounds in a patient with suspected pneumothorax can prompt immediate intervention, such as notifying the healthcare provider for further evaluation and treatment. This knowledge enhances patient safety and outcomes in clinical practice.

Correct Answer: A

Rationale: In this scenario, option A, "Decreased wheezing on auscultation," suggests that the albuterol medication is effective for the client with asthma. Wheezing is a common symptom of asthma caused by airway constriction and inflammation. Albuterol is a bronchodilator that works to relax the airway muscles, leading to improved airflow and decreased wheezing. Therefore, a reduction in wheezing indicates that the medication is effectively dilating the airways and improving the client's breathing. Options B, C, and D are incorrect. An increased heart rate (option B) could indicate a side effect of albuterol, but it does not necessarily indicate the effectiveness of the medication in treating asthma. A decreased oxygen saturation (option C) would be a concerning finding, as it suggests inadequate oxygenation despite treatment. Mild hand tremors (option D) are a known side effect of albuterol but do not directly reflect the medication's effectiveness in treating asthma. Educationally, it is crucial for nurses to understand the expected outcomes and responses to specific medications used in treating respiratory conditions like asthma. Monitoring for clinical indicators of effectiveness, such as improved respiratory function like decreased wheezing, helps nurses assess the client's response to treatment and make informed decisions about ongoing care and interventions. This knowledge enhances patient safety and improves overall health outcomes for individuals with asthma.

Correct Answer: B

Rationale: In teaching a client with pulmonary fibrosis about energy conservation techniques, the most effective strategy is option B) Sitting while performing tasks like cooking. This is because sitting while engaging in activities reduces the energy expenditure and strain on the respiratory system, which is crucial for individuals with compromised lung function like pulmonary fibrosis. By sitting, the client can conserve energy and reduce the workload on their lungs, thus preventing excessive fatigue and shortness of breath. Option A) Performing all activities in the morning may not be the most effective strategy as energy levels fluctuate throughout the day, and the client may still experience fatigue when performing tasks later in the day. Option C) Increasing physical activity to build stamina is not suitable for individuals with pulmonary fibrosis because excessive physical exertion can lead to increased oxygen demand, exacerbating respiratory distress. Option D) Avoiding rest breaks to maintain momentum is counterproductive as rest breaks are essential for individuals with pulmonary fibrosis to prevent overexertion and conserve energy. Educationally, it is important to emphasize the rationale behind energy conservation techniques for clients with pulmonary fibrosis to help them manage their condition effectively and improve their quality of life. By providing specific strategies like sitting while performing tasks, nurses can empower clients to better manage their symptoms and reduce the impact of pulmonary fibrosis on their daily activities.

Correct Answer: B

Rationale: In this scenario, option B is the most concerning ABG result for a client admitted with acute respiratory distress. A pH of 7.32 indicates acidosis, which can be life-threatening. A PaO2 of 50 mmHg is significantly below the normal range (80-100 mmHg), indicating poor oxygenation. A PaCO2 of 55 mmHg is elevated, suggesting respiratory acidosis due to inadequate ventilation. Option A has a normal pH and PaCO2 but a slightly lower PaO2, which is concerning but not as critical as option B. Option C shows an elevated pH, which indicates alkalosis, and a low PaCO2, suggesting respiratory alkalosis, but the PaO2 is slightly low. Option D has normal values for pH and PaCO2, with a slightly higher PaO2, indicating better oxygenation compared to option B. Educationally, understanding ABG values is crucial for assessing a patient's respiratory status and guiding oxygen therapy interventions. This question highlights the importance of interpreting ABG results in the context of respiratory distress to make timely and appropriate clinical decisions to optimize patient outcomes.