The nurse is monitoring a patient after thoracic surgery. Which finding is most concerning?

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: 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.

Correct Answer: A

Rationale: In the context of oxygen therapy, understanding the side effects of medications commonly prescribed to patients receiving this treatment is crucial for nurses. In this scenario, the correct answer is A) Peripheral neuropathy. Isoniazid (INH) is a medication used to treat tuberculosis but is known to cause peripheral neuropathy as a side effect. This condition is characterized by damage to the peripheral nerves, leading to symptoms like numbness, tingling, and weakness in the extremities. Option B) Orange discoloration of body fluids is not a known side effect of isoniazid and is more commonly associated with medications like rifampin. Option C) Visual changes are not typically linked to isoniazid use but can occur with other medications or conditions. Option D) Hearing loss is not a recognized side effect of isoniazid but may be seen with certain antibiotics like aminoglycosides. Educationally, this question highlights the importance of monitoring for specific side effects of medications, especially in patients with tuberculosis who are already vulnerable. Nurses need to be vigilant in assessing for potential adverse reactions to provide safe and effective care to their patients undergoing treatment with isoniazid.

Correct Answer: B

Rationale: In a patient with acute respiratory distress syndrome (ARDS), the finding that requires immediate intervention is option B) Oxygen saturation of 85% despite oxygen therapy. This is because a low oxygen saturation level indicates severe hypoxemia, which can lead to tissue hypoxia and organ dysfunction. In ARDS, maintaining adequate oxygenation is crucial to prevent further complications. Option A) Respiratory rate of 22 breaths per minute is within the normal range and may not necessarily indicate an immediate need for intervention. Option C) Bilateral crackles heard on auscultation are indicative of fluid in the lungs, which is common in ARDS but may not always require immediate intervention unless accompanied by severe respiratory distress. Option D) Use of accessory muscles for breathing suggests respiratory distress but may not be as urgent as addressing severe hypoxemia. Educationally, understanding the importance of monitoring oxygen saturation levels in ARDS patients is vital for healthcare professionals to provide timely and appropriate interventions. This question highlights the critical role of oxygen therapy in managing ARDS and the need to prioritize oxygenation in the care of these patients to prevent further deterioration.