The nurse palpates the posterior chest while the patient says "99" and notes absent fremitus. Which action should the nurse take next?

Correct Answer: D

Rationale: The correct answer is D: Auscultate anterior and posterior breath sounds bilaterally. This is the next appropriate action after noting absent fremitus during palpation of the posterior chest. Auscultation helps assess breath sounds and detects abnormalities such as wheezing or crackles. It provides valuable information about the patient's lung health and can help identify potential respiratory issues. Palpating the anterior chest or observing for barrel chest (choice A) is not the immediate priority when fremitus is absent. Encouraging the patient to turn, cough, and deep breathe (choice B) may be beneficial but does not directly address the absence of fremitus. Reviewing the chest x-ray report for evidence of pneumonia (choice C) is important but does not address the immediate need to further assess breath sounds in this scenario.

Correct Answer: D

Rationale: The correct answer is D: Administer a bronchodilator. This is the priority intervention because bronchodilators help to quickly open the airways during an asthma attack, improving breathing. Administering a bronchodilator is crucial for managing acute asthma symptoms. Encouraging the patient to avoid triggers (choice B) is important for long-term asthma management but not the priority during an acute attack. Administering an inhaled corticosteroid (choice C) is more for long-term control and prevention of asthma symptoms, not for immediate relief during an attack. Choice A is a duplicate of the correct answer and does not provide additional information.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the priority in a patient with heart failure experiencing shortness of breath to improve oxygenation and reduce workload on the heart. Oxygen therapy helps alleviate symptoms and prevent further complications. Administering morphine (choice B) is not the first priority as it can depress the respiratory system and mask important symptoms. Monitoring respiratory status (choice C) is important but providing oxygen takes precedence to address the immediate need for improved oxygenation. Choice D is a duplicate of choice A, making it incorrect.

Correct Answer: D

Rationale: The correct answer is D: Monitor the patient's oxygen saturation levels. The priority action is to assess the patient's oxygen saturation as the vital signs indicate potential hypoperfusion. This could be due to inadequate tissue oxygenation, which is critical to address to prevent further deterioration. Administering a vasopressor (A) may further decrease blood pressure. Administering a loop diuretic (B) is not appropriate as the patient is hypotensive. Administering short-acting insulin (C) is not indicated in this scenario. Monitoring oxygen saturation levels will provide crucial information on the patient's respiratory status and guide appropriate interventions.

Correct Answer: C

Rationale: The correct answer is C: Administer insulin therapy. Blurred vision in a patient with a history of diabetes indicates possible hyperglycemia, requiring immediate insulin therapy to lower blood glucose levels and prevent further complications. Administering insulin is the priority to address the root cause. Monitoring blood glucose levels (A) is important but not the priority over administering insulin therapy. Administering pain medication (B) and a pain reliever (D) are not appropriate actions for blurred vision in a diabetic patient.