The nurse prepares to administer a new order for a non-rebreather mask. Which action is most important for the nurse to take?

Correct Answer: A

Rationale: The correct answer is A: Ensure the reservoir bag is inflated before placing it on the patient. This is important because an inflated reservoir bag ensures a high concentration of oxygen is delivered to the patient. If the bag is not inflated, the mask will not provide the intended oxygen therapy. Choice B is incorrect as the flow rate for a non-rebreather mask is typically set at 10-15 liters per minute to ensure adequate oxygen delivery. Choice C is also incorrect as assessing the patient's ability to breathe independently is important but not the most crucial step before administering the mask. Choice D is incorrect as monitoring arterial blood gas levels is important but not the immediate action needed before administering the mask.

Correct Answer: A

Rationale: The correct answer is A: Perform tracheostomy suctioning using sterile technique. This is the most appropriate action because thick secretions can obstruct the tracheostomy tube, leading to respiratory distress. Suctioning helps clear the airway and maintain patency. Sterile technique is crucial to prevent introducing infection. Incorrect Choices: B: Increasing oxygen flow does not directly address the issue of thick secretions in the tracheostomy tube. C: Instilling normal saline may further increase secretions and can potentially cause aspiration. D: Encouraging the patient to take deep breaths may not effectively clear the thick secretions from the tracheostomy tube.

Correct Answer: B

Rationale: The correct answer is B: Oxygen saturation of 85%. This assessment finding is most concerning because it indicates severe hypoxemia, which can lead to tissue damage and respiratory failure. A low oxygen saturation level of 85% requires immediate intervention to prevent further complications. Rationale: 1. Crackles heard in the lung bases (Choice A) are common in pneumonia but do not indicate severe hypoxemia. 2. Cough with yellow sputum production (Choice C) is a common symptom of pneumonia but does not directly reflect the patient's oxygenation status. 3. Respiratory rate of 22 breaths per minute (Choice D) is within the normal range and may not necessarily indicate severe respiratory distress. In summary, the oxygen saturation of 85% is the most concerning assessment finding as it directly reflects the patient's oxygenation status and requires immediate attention to prevent complications.

Correct Answer: B

Rationale: The correct answer is B: Spiral CT scan. This test is the priority for diagnosing pulmonary embolism as it provides quick and accurate visualization of blood flow in the lungs. Chest x-ray (A) may not show definitive signs of embolism. Pulmonary function test (C) measures lung function but does not directly diagnose embolism. Arterial blood gas analysis (D) may show respiratory status but does not confirm the presence of embolism. Spiral CT scan is the gold standard for diagnosing pulmonary embolism due to its high sensitivity and specificity.

Correct Answer: C

Rationale: The correct answer is C: Perform a peak expiratory flow reading. This is the priority intervention because it helps assess the severity of the patient's asthma exacerbation objectively. By measuring the peak expiratory flow, the nurse can determine the degree of airflow limitation and response to treatment. This information guides appropriate interventions and helps in monitoring the effectiveness of the treatment. Notification of the healthcare provider (choice A) can be important but assessing the patient's respiratory status takes precedence. Teaching proper inhaler technique (choice B) and assessing adherence to maintenance medication (choice D) are important interventions but not the immediate priority when the patient is experiencing increased symptoms.