Which finding in a patient receiving oxygen therapy requires immediate intervention?

Correct Answer: B

Rationale: In this scenario, the correct answer is option B, which is an oxygen saturation of 86%. Oxygen saturation represents the amount of oxygen carried by hemoglobin in the blood. A saturation level of 86% is considered critically low and requires immediate intervention to prevent hypoxia, which can lead to serious complications like organ damage or failure. Option A, dryness around the nostrils, is not an immediate concern and can be addressed with simple interventions like humidification. Option C, a respiratory rate of 20 breaths per minute, falls within the normal range and does not indicate an urgent issue. Option D, occasional nasal bleeding, while concerning, is not as critical as the low oxygen saturation level and can be managed while addressing the oxygenation problem. Educationally, understanding the importance of monitoring oxygen saturation levels is crucial for healthcare professionals, especially in patients receiving oxygen therapy. This knowledge helps in early identification of hypoxia and prompt intervention to ensure patient safety and well-being. It also highlights the significance of prioritizing interventions based on the severity of the patient's condition.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Collaborate with a speech therapist for evaluation. This is the most appropriate action because difficulty swallowing, also known as dysphagia, in a patient with a tracheostomy can have serious implications such as aspiration, respiratory distress, and inadequate nutrition. Speech therapists are trained to assess and manage swallowing disorders, including those related to tracheostomies. They can perform a comprehensive evaluation to determine the cause of the swallowing difficulty and recommend appropriate interventions, such as modified diets or exercises to improve swallowing function. Option A, inflating the tracheostomy cuff fully, is incorrect as it can further impede swallowing function and increase the risk of aspiration. Option C, encouraging the patient to eat soft foods only, is incorrect because without a proper evaluation, it is unsafe to assume that changing the food consistency will address the swallowing issue. Option D, increasing oral fluid intake, is also incorrect because it does not address the underlying cause of the swallowing difficulty and may not be safe if there is a risk of aspiration. In an educational context, it is important for nurses to understand the significance of dysphagia in patients with tracheostomies and the appropriate steps to take when a patient reports difficulty swallowing. Collaborating with other healthcare professionals, such as speech therapists, is essential in providing holistic care and ensuring patient safety and well-being. Nurses must prioritize patient assessment, interdisciplinary communication, and evidence-based practice to deliver high-quality care in complex clinical situations like this one.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Chronic hypoxia. Clubbing of the fingers, also known as digital clubbing, is a physical sign often associated with chronic hypoxia, which is a common complication in patients with chronic bronchitis. When the body is chronically deprived of oxygen, it can lead to changes in the tissues of the fingers, resulting in clubbing. Option B) Pulmonary embolism is incorrect in this case because clubbing of the fingers is not typically associated with this condition. Pulmonary embolism is a sudden blockage in one of the pulmonary arteries in the lungs, usually caused by a blood clot. Option C) Pneumothorax is also an incorrect choice as clubbing of the fingers is not a typical symptom of this condition. Pneumothorax is characterized by the presence of air in the pleural space, leading to lung collapse. Option D) Asthma exacerbation is not the correct answer because clubbing of the fingers is not a common manifestation of an asthma exacerbation. Asthma exacerbations are typically associated with wheezing, shortness of breath, and coughing. Educationally, understanding the correlation between clubbing of the fingers and chronic hypoxia in patients with chronic bronchitis is crucial for nurses assessing respiratory conditions. Recognizing this physical sign can aid in early identification of oxygenation issues and prompt intervention to improve patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) Take this medication twice daily as prescribed. Rationale: This is the most important teaching point because salmeterol is a long-acting beta agonist used for maintenance treatment of asthma, not for acute asthma attacks. Taking the medication as prescribed ensures optimal control of asthma symptoms and decreases the risk of exacerbations. Consistent dosing is crucial for the medication to be effective in managing asthma. Option A) Use the inhaler during an acute asthma attack is incorrect because salmeterol is not a rescue inhaler and should not be used for immediate relief during an asthma attack. Using it during an acute attack can be dangerous as it does not provide quick relief. Option C) Rinse your mouth after each use to prevent infections is important for corticosteroid inhalers, not for salmeterol. Salmeterol is a long-acting bronchodilator and does not typically cause oral infections. Option D) Shake the inhaler before each use is incorrect for salmeterol as it is not a requirement for this type of inhaler. Shaking the inhaler before use is typically necessary for metered-dose inhalers containing corticosteroids to ensure proper medication dispersion. Educational Context: This question highlights the importance of understanding the specific instructions for different asthma medications. Educating patients about their prescribed medications is essential for effective asthma management and improving patient outcomes. It is crucial for nurses to provide accurate information to patients to ensure they use their medications correctly and achieve optimal control of their asthma.

Correct Answer: B

Rationale: The correct answer is B) Assess for allergy to shellfish. Before a spiral CT scan, the nurse must prioritize assessing for shellfish allergy because the contrast dye used in the scan may contain iodine, a common allergen found in shellfish. An undiagnosed shellfish allergy could lead to a severe allergic reaction during the scan, jeopardizing the patient's safety. Option A) Ensure the patient has been NPO for 6 hours is incorrect as it pertains to fasting before procedures involving sedation, not specifically related to a CT scan. Option C) Check the patient's blood glucose levels is incorrect as it is not directly relevant to preparing for a CT scan and does not address the immediate safety concern of potential contrast dye allergy. Option D) Monitor the patient's oxygen saturation is incorrect as it is important but not the priority before the CT scan. Assessing for an allergy to shellfish takes precedence for patient safety. Educationally, understanding the rationale behind prioritizing assessments before procedures is crucial for nurses to provide safe and effective care. This scenario highlights the importance of thorough patient assessments and knowledge of potential risks associated with diagnostic procedures, emphasizing the need for a holistic approach to patient care.