The nurse observes a drop in oxygen saturation from 92% to 86% in a patient ambulating with COPD. What is the nurse's priority?

Correct Answer: B

Rationale: In this scenario, the nurse's priority should be option B) Assist the patient back to bed. This is the correct choice because a drop in oxygen saturation in a patient with COPD while ambulating indicates a potential worsening of their condition. Moving the patient back to bed will help decrease their oxygen demand and workload on the respiratory system, potentially improving oxygenation. Option A) Increase oxygen flow rate is incorrect because simply increasing oxygen flow may not address the underlying issue causing the drop in saturation. It is essential to assess the patient's overall condition first. Option C) Reassess oxygen saturation in 5 minutes is not the priority because the immediate action should be taken to address the drop in oxygen saturation and ensure the patient's safety. Option D) Encourage pursed-lip breathing is not the priority in this situation as it may not be effective enough to quickly improve oxygen saturation in a patient experiencing a drop while ambulating. In an educational context, this question highlights the importance of prioritizing patient safety and addressing acute changes in oxygenation levels promptly, especially in individuals with underlying respiratory conditions like COPD. Understanding the significance of oxygen saturation monitoring and appropriate interventions is crucial for nurses caring for patients with compromised respiratory function.

Correct Answer: C

Rationale: The correct answer is C) Assess for tube obstruction. When a patient with a chest tube exhibits subcutaneous emphysema, which is the accumulation of air under the skin, the nurse's first action should be to assess for tube obstruction. Subcutaneous emphysema can indicate that air is not draining properly through the chest tube, which can lead to serious complications such as a tension pneumothorax. Notifying the healthcare provider (option A) may be necessary after assessing for tube obstruction, but it is not the first action. Repositioning the chest tube (option B) should only be done under the guidance of a healthcare provider to prevent further complications. Monitoring the area and documenting findings (option D) is important but not the priority when the patient's condition may be deteriorating due to a possible tube obstruction. In an educational context, understanding the priority actions in managing chest tube complications is crucial for nurses caring for patients with respiratory issues. Assessing for tube obstruction ensures timely intervention to prevent respiratory compromise and further complications, highlighting the importance of prompt and accurate nursing assessment skills in critical situations.

Correct Answer: B

Rationale: In the context of a patient with bacterial pneumonia exhibiting coarse crackles and thick sputum, the correct action to promote airway clearance is to teach the pursed-lip breathing technique (Option B). This technique helps improve oxygenation and facilitates the removal of secretions by creating positive pressure in the airways during exhalation. Option A, restricting oral fluids during the day, is incorrect as hydration is essential for thinning respiratory secretions, making them easier to expectorate. Option C, encouraging the patient to wear the nasal O2 cannula, is also incorrect because while oxygen therapy may be necessary, it does not directly address airway clearance. Option D, assisting the patient to splint the chest when coughing, is not the most effective intervention for promoting airway clearance in this scenario. From an educational standpoint, understanding the rationale behind the correct answer is crucial for nursing students preparing for the NCLEX exam. Teaching them the pursed-lip breathing technique equips them with a practical skill that can be applied in real clinical situations to improve patient outcomes, especially in cases of respiratory conditions like pneumonia where airway clearance is a priority.

Correct Answer: D

Rationale: The correct answer is D) Assist the patient with physical therapy. Rationale: 1. **Correct Answer (D):** Physical therapy helps prevent DVT by promoting circulation and preventing blood stasis. Physical activity encourages muscle contractions, which in turn aids in venous return, reducing the risk of clot formation. 2. **Incorrect Answers:** - A) Encouraging early ambulation is important in preventing DVT, but physical therapy involves more structured exercise routines tailored to the patient's needs. - B) While compression stockings can help with DVT prevention, they are not as effective as physical therapy in promoting muscle movement and circulation. - C) Administering aspirin is not primarily used for DVT prevention. Aspirin is more commonly used for its antiplatelet effects in conditions like heart disease. 3. **Educational Context:** - Understanding the importance of preventing DVT postoperatively is crucial for nurses caring for surgical patients. - Physical therapy plays a significant role in preventing complications like DVT in immobile or postoperative patients by promoting mobility and circulation. - Nurses should be knowledgeable about various strategies to prevent DVT and tailor interventions based on individual patient needs to ensure optimal outcomes.

Correct Answer: B

Rationale: In this scenario, the priority intervention for a patient with a history of myocardial infarction (MI) complaining of chest pain is to administer morphine (Option B). The rationale behind choosing morphine as the correct answer is that it helps to relieve chest pain by decreasing the workload of the heart and reducing anxiety, thereby improving oxygenation to the heart muscle. This is crucial in a patient with a history of MI as chest pain could be indicative of ongoing ischemia or infarction. Administering nitroglycerin (Option A) is also a common intervention for chest pain in MI patients, as it helps to dilate blood vessels and improve blood flow to the heart. However, in this case, morphine takes precedence due to its broader pain-relieving and calming effects. Providing pain relief (Option C) is a general intervention but does not address the specific needs of a patient with a history of MI experiencing chest pain. Administering oral anticoagulants (Option D) is not appropriate as the immediate concern is managing the current chest pain and potential cardiac complications. Educationally, understanding the rationale behind prioritizing certain interventions in acute cardiac situations like MI is crucial for nurses to provide timely and effective care, which can ultimately save lives and prevent further cardiac damage.