Which assessment finding in a patient with pneumonia is most concerning?

Correct Answer: B

Rationale: The correct answer is B: Oxygen saturation of 86% on room air. This finding is most concerning in a patient with pneumonia because it indicates severe hypoxemia, which can lead to tissue damage and organ failure. Low oxygen saturation levels can be life-threatening and require immediate intervention. Rationale: 1. Oxygen saturation is a direct indicator of how well the lungs are oxygenating the blood. 2. A saturation level of 86% on room air is significantly below the normal range (typically 95-100%). 3. Hypoxemia can lead to tissue hypoxia, organ dysfunction, and even respiratory failure if left untreated. 4. Prompt oxygen therapy is necessary to improve oxygenation and prevent further complications. Summary: A: Respiratory rate of 24 breaths per minute - Elevated respiratory rate is common in pneumonia but not as concerning as severe hypoxemia. C: Fever of 100.4°F (38°C) - Fever is a common symptom of pneumonia but

Correct Answer: B

Rationale: The correct answer is B: Sputum culture. The priority diagnostic test for suspected tuberculosis is sputum culture because it directly identifies the presence of Mycobacterium tuberculosis. This test helps confirm the diagnosis and determine the appropriate treatment. Chest x-ray (A) is important but may not definitively diagnose TB. Mantoux test (C) checks for exposure but not active infection. Complete blood count (D) can show signs of infection but does not confirm TB.

Correct Answer: A

Rationale: The priority nursing intervention for a patient with newly diagnosed pulmonary embolism (PE) is to administer prescribed anticoagulants (Choice A). This is because anticoagulants help to prevent further clot formation and reduce the risk of complications such as worsening of the PE or development of additional blood clots. Administering anticoagulants promptly is crucial in managing PE and improving outcomes for the patient. Positioning the patient supine and applying oxygen (Choice B) may be important, but it is not the priority over administering anticoagulants. Preparing for chest x-ray and CT scan (Choice C) and starting IV fluids (Choice D) are important assessments and interventions but are not the priority in the immediate management of PE.

Correct Answer: B

Rationale: The correct answer is B, Oxygen saturation of 88%. A low oxygen saturation level of 88% indicates hypoxemia, which can be life-threatening and requires immediate attention to prevent complications like organ damage or respiratory failure. A: Mild discomfort at the puncture site is expected after a thoracentesis and can be managed with pain relief measures. C: Removing 300 mL of pleural fluid is a normal part of the procedure and does not require immediate attention unless signs of complications arise. D: A respiratory rate of 18 breaths per minute is within the normal range, so it does not require immediate attention. In summary, a low oxygen saturation level is the most critical finding that needs prompt intervention compared to the other choices.

Correct Answer: C

Rationale: The correct answer is C: Check all connections for leaks. The priority action is to identify and address the source of the air leak to prevent complications such as tension pneumothorax. Clamping the chest tube (A) can lead to a life-threatening situation. Notifying the healthcare provider (B) is important but not the immediate action. Repositioning the chest tube (D) does not address the air leak issue. Checking all connections for leaks (C) ensures the integrity of the chest tube system and allows for prompt intervention.