The nurse observes that a patient with respiratory disease experiences a decrease in SpO2 from 93% to 88% while the patient is ambulating. What is the priority action of the nurse?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Administer PRN supplemental O2. When a patient's SpO2 drops during ambulation, it indicates increased oxygen demand that is not being met adequately. Administering supplemental oxygen in this situation helps to ensure that the patient's oxygen saturation remains within a safe range, preventing hypoxia and potential complications. Option A) Notifying the health care provider can be important but may cause a delay in providing immediate care to the patient. Option C) Documenting the response to exercise is important but not the most immediate action when the patient's oxygen saturation is dropping. Option D) Encouraging the patient to pace activity is not enough to address the immediate need for supplemental oxygen when SpO2 is decreasing during ambulation. Educationally, this question highlights the importance of recognizing signs of decreased oxygen saturation in patients with respiratory diseases and the prompt administration of supplemental oxygen to maintain adequate oxygen levels during increased activity. It reinforces the crucial role of nurses in monitoring patients' responses to interventions and taking immediate action to ensure patient safety and well-being.

Correct Answer: A

Rationale: In the context of oxygen therapy and chest tube management, the correct answer to the question is option A) Continuous bubbling in the water-seal chamber. This finding requires immediate action because it indicates an air leak, which can compromise the effectiveness of the chest tube drainage system and lead to potentially serious complications such as pneumothorax. Option B) Drainage of 60 mL in the past hour is within the expected range for chest tube drainage and does not necessarily warrant immediate action unless there are other concerning signs or symptoms present. Option C) Dressing dry and intact at the insertion site is a positive finding indicating proper wound care and does not require immediate action. Option D) Tidaling observed in the water-seal chamber is a normal finding and indicates proper functioning of the chest tube drainage system. Educationally, understanding the significance of each finding in chest tube management is crucial for nurses caring for patients requiring oxygen therapy. Recognizing abnormal findings and knowing when to take immediate action is essential to prevent complications and ensure optimal patient outcomes. Regular monitoring and assessment of chest tube systems are vital components of nursing care in respiratory and critical care settings.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Pneumococcal pneumonia. Rust-colored sputum is a classic indicator of pneumococcal pneumonia, caused by Streptococcus pneumoniae. This bacterium leads to the destruction of lung tissue, causing bleeding and the presence of rusty-colored sputum. Understanding this connection is crucial for nurses to accurately assess and diagnose patients presenting with this symptom. Option A) Tuberculosis typically presents with a chronic cough, blood-tinged sputum, weight loss, and night sweats. While tuberculosis can cause hemoptysis, it does not usually result in rust-colored sputum. Option B) Pulmonary embolism manifests with sudden onset shortness of breath, chest pain, and coughing up blood. Rust-colored sputum is not a common presentation of pulmonary embolism. Option D) Bronchitis is characterized by a productive cough with clear, white, yellow, or green sputum. Rust-colored sputum is not typically associated with bronchitis. Educationally, understanding the specific sputum characteristics associated with different respiratory conditions is vital for accurate clinical assessments and interventions. Nurses must be able to differentiate between various respiratory conditions based on presenting symptoms to provide timely and appropriate care to patients.

Correct Answer: B

Rationale: In this scenario, selecting option B, instructing the patient to lean forward and pinch the nostrils, is the most appropriate initial action by the nurse when a patient reports frequent nosebleeds. This approach helps to apply direct pressure to the source of bleeding and promotes clot formation to stop the bleeding effectively. Option A, applying a cold compress to the back of the neck, is not the most appropriate initial action for nosebleeds because direct pressure at the source of bleeding is crucial to stop the flow of blood. Option C, inserting nasal packing to stop the bleeding, is an invasive intervention that should be reserved for severe or uncontrolled nosebleeds after initial measures have failed. It is not the first-line action. Option D, encouraging the patient to lie down and rest, is not the best initial response to nosebleeds. While rest is important, the immediate focus should be on stopping the bleeding using direct pressure as described in option B. Educationally, it is important for nurses to understand the sequential approach to managing nosebleeds, starting with simple, non-invasive techniques like direct pressure. This helps prevent unnecessary escalation of interventions and ensures appropriate and timely care for patients experiencing this common issue.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Oxygen saturation of 84% on room air. This finding requires immediate action because it indicates severe hypoxemia, which can lead to serious complications such as organ damage and respiratory failure. Oxygen saturation below 90% is considered low and requires intervention to prevent further deterioration of the patient's condition. Option A (Temperature of 101.3°F) may be indicative of infection but does not require immediate action as it is not life-threatening in the same way as severe hypoxemia. Option B (Productive cough with yellow sputum) is common in pneumonia but does not indicate an immediate need for intervention. Option D (Coarse crackles heard in the lung bases) may suggest fluid in the lungs but does not require immediate action as addressing hypoxemia is the priority in this case. Educationally, this question highlights the importance of recognizing and prioritizing critical assessment findings in patients with respiratory conditions. Understanding the significance of oxygen saturation levels and the potential consequences of severe hypoxemia is crucial for healthcare providers to deliver prompt and effective care to patients in respiratory distress.