Which assessment finding in a patient with pneumonia requires immediate action?

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.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Oxygen saturation levels. When a patient with COPD experiences worsening shortness of breath, assessing oxygen saturation levels is critical because hypoxemia can significantly impact their condition. Low oxygen saturation levels can indicate respiratory distress and the need for supplemental oxygen therapy to improve oxygenation and alleviate symptoms. Option A) Respiratory rate and effort is important in assessing respiratory status, but in a patient with COPD experiencing worsening shortness of breath, checking oxygen saturation levels takes precedence as it provides more immediate information about oxygen exchange. Option C) Lung sounds for wheezing or crackles are important in assessing respiratory conditions, but in this case, the priority is to determine the oxygenation status of the patient. Option D) Peak expiratory flow rate is more commonly used in conditions like asthma to monitor airway obstruction, and it is not the first assessment to perform in a COPD patient with worsening shortness of breath. Educationally, understanding the prioritization of assessments in patients with COPD is crucial for nurses and healthcare providers to effectively manage and intervene in respiratory distress situations. By recognizing the significance of assessing oxygen saturation levels promptly, healthcare professionals can make timely interventions to improve patient outcomes and prevent respiratory complications.

Correct Answer: B

Rationale: In a patient with acute bronchitis, an oxygen saturation of 89% requires immediate attention. Oxygen saturation below 90% indicates hypoxemia, which can lead to serious complications such as respiratory failure and organ damage. Addressing this low oxygen level promptly is crucial to prevent further deterioration and ensure adequate oxygen delivery to the body's tissues. The other options are not as immediately concerning as a low oxygen saturation level. - A persistent dry cough is a common symptom of bronchitis but does not indicate an immediate threat to the patient's condition. - Coarse crackles in both lungs may suggest the presence of mucus or inflammation but do not necessarily require immediate intervention. - Increased sputum production is a typical symptom of bronchitis and may indicate the body's response to infection but does not pose an immediate threat to the patient's oxygenation. Educationally, understanding the significance of oxygen saturation levels in respiratory conditions is vital for healthcare providers to prioritize interventions and provide timely, effective care. Monitoring and interpreting oxygen saturation levels accurately can help prevent complications and guide treatment decisions in patients with respiratory illnesses like acute bronchitis.

Correct Answer: D

Rationale: In this scenario, the nurse's priority action should be to assess the patient's technique for inhaler use (Option D). Proper inhaler technique is crucial for the effective delivery of medication in asthma management. By assessing the patient's technique, the nurse can ensure that the medication is being administered correctly, maximizing its effectiveness and reducing the risk of complications or worsening symptoms. Option A is not the priority because before considering a change in treatment, it is essential to first ensure that the current treatment is being optimally administered. Option B, monitoring peak flow daily, is important in asthma management but not the priority in this situation where assessing inhaler technique is more immediate. Option C, encouraging inhaler use before exercise, is beneficial but does not address the primary concern of assessing and ensuring proper inhaler technique. Educationally, this question highlights the importance of proper inhaler technique in asthma management. It emphasizes the role of healthcare providers in assessing and educating patients on correct medication administration to improve outcomes and patient safety. Nurses play a vital role in patient education and should prioritize assessing and addressing any issues with inhaler technique to optimize treatment effectiveness.

Correct Answer: B

Rationale: In this scenario, the nurse's priority action should be to select option B, which is to assess the patient's vital signs and oxygen saturation. This choice is the most appropriate initial step because hemoptysis can indicate a potentially serious condition, such as pulmonary embolism or pneumonia, especially in a patient on anticoagulant therapy. Assessing vital signs and oxygen saturation will provide crucial information about the patient's current status and help guide further interventions. Option A (Stop anticoagulant therapy immediately) is not the priority as it may exacerbate the patient's underlying condition and should be determined by the healthcare provider. Option C (Notify the healthcare provider immediately) is important but not the immediate action needed in this case. Option D (Administer vitamin K to reverse anticoagulation) is not appropriate as the priority is to assess the patient's condition first before considering any interventions that may affect their anticoagulation status. In an educational context, understanding the rationale behind prioritizing actions in critical situations like this is essential for nurses to provide safe and effective care. It highlights the importance of quick and accurate assessment to ensure timely and appropriate interventions to address potentially life-threatening complications.