What is the nurse's first action when a patient with a chest tube exhibits subcutaneous emphysema?

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: 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.

Correct Answer: B

Rationale: In this scenario, the nurse should prioritize option B: Notify the patient's health care provider. This action is crucial because the patient is presenting with symptoms that are indicative of a possible pulmonary embolism, a serious condition that requires immediate medical attention. Contacting the healthcare provider allows for prompt assessment, further diagnostic testing, and initiation of appropriate treatment. Option A (Administer anticoagulant drug therapy) is incorrect because administering medication without a proper diagnosis and healthcare provider's orders can be dangerous and may worsen the patient's condition if the diagnosis is incorrect. Option C (Prepare patient for a spiral CT) is also incorrect as it involves a diagnostic procedure that should be ordered by the healthcare provider after assessment and evaluation. It is not the nurse's role to independently order diagnostic tests. Option D (Elevate the head of the bed to a semi-Fowler's position) is a supportive measure but is not the priority in this situation. The patient's critical condition requires immediate medical intervention. Educationally, this question highlights the importance of prioritizing patient care based on assessment findings and the urgency of the situation. Nurses need to recognize emergent situations, collaborate with healthcare providers, and follow proper protocols to ensure optimal patient outcomes.

Correct Answer: C

Rationale: In this scenario, the priority nursing intervention for a patient receiving chemotherapy and at risk for infection is to administer antifungal therapy (Option C). The rationale behind this is that chemotherapy often suppresses the immune system, making patients more susceptible to fungal infections. Antifungal therapy helps prevent and treat these infections, which can be life-threatening in immunocompromised individuals. Administering antibiotic therapy (Option A) or antibiotics (Option D) may be necessary for bacterial infections, but in this case, the patient is specifically at risk for fungal infections due to chemotherapy. Administering antifungal medication (Option B) is a redundant option as it conveys the same meaning as Option C. Educationally, this question highlights the importance of tailoring interventions to the specific needs of each patient based on their underlying conditions and treatments. Understanding the rationale behind prioritizing certain interventions in different clinical situations is crucial for nurses to provide safe and effective care to their patients, especially those with compromised immune systems.