Which nursing diagnosis is the priority for a patient with low O2 saturation?

Correct Answer: D

Rationale: In this scenario, the correct answer is option D) Risk for infection. The priority nursing diagnosis for a patient with low O2 saturation is assessing and addressing the risk for infection. When a patient has low O2 saturation, it indicates that all body tissues are not receiving adequate oxygen, making them more susceptible to infections due to compromised immunity. Choosing option D as the priority nursing diagnosis is crucial because infections can further compromise the body's ability to oxygenate tissues, worsening the existing oxygenation problem. By addressing the risk for infection, nurses can help prevent potential complications that could exacerbate the patient's condition. Options A, B, and C are incorrect in this context because while impaired gas exchange, ineffective breathing, and pain are important nursing diagnoses to consider for a patient with low O2 saturation, addressing the risk for infection takes precedence due to the potential for further deterioration of the patient's condition. Educationally, understanding the priority nursing diagnosis in a situation like this is essential for providing safe and effective patient care. It highlights the importance of critical thinking in prioritizing patient needs based on the assessment data. By recognizing the significance of addressing the risk for infection in a patient with low O2 saturation, nurses can intervene early to prevent complications and promote optimal patient outcomes.

Correct Answer: C

Rationale: The correct answer is C) Montelukast. Montelukast is a leukotriene receptor antagonist used in the management of asthma. It is important to note that β-blockers, such as Propranolol (option B), can cause bronchospasm in patients with asthma. β-blockers can block the bronchodilatory effects of beta-agonist medications like Albuterol (option A) and Salmeterol (option D), leading to worsening of asthma symptoms. Therefore, in patients with asthma, it is crucial to avoid β-blockers if possible to prevent exacerbation of bronchospasm. Educational Context: Understanding the potential adverse effects of medications in specific patient populations, such as asthma patients, is essential for healthcare providers. It is crucial to consider a patient's medical history, comorbidities, and potential drug interactions when selecting medications to optimize patient outcomes. Educating healthcare professionals about these interactions ensures safe medication practices and improves patient care. In the context of the NCLEX exam, this question assesses the candidate's knowledge of pharmacological principles and their ability to apply this knowledge to clinical scenarios.

Correct Answer: A

Rationale: The correct answer is option A) A cycle involving oxygen circulation in the atmosphere. This option is correct because the oxygen cycle refers to the continuous process of oxygen being circulated throughout the atmosphere via processes such as photosynthesis by plants and respiration by living organisms. Option B) A process of nitrogen fixation is incorrect because nitrogen fixation is a different process that involves converting atmospheric nitrogen into a form that plants can absorb, and it does not directly relate to the circulation of oxygen. Option C) A cycle of carbon storage is incorrect because the carbon cycle is a separate process that involves the movement of carbon through various reservoirs like the atmosphere, oceans, and living organisms, and it does not specifically involve oxygen circulation. Option D) A method of water purification is incorrect because water purification is a process that removes contaminants from water to make it safe for consumption, and it is not related to the circulation of oxygen in the atmosphere. Educationally, understanding the oxygen cycle is crucial for healthcare professionals, especially nurses, as it is fundamental to the process of respiration in humans. By grasping how oxygen is produced and utilized in the environment, nurses can better comprehend the importance of oxygenation for patient health and the implications of oxygen therapy in clinical practice. Understanding basic biological cycles like the oxygen cycle enhances a nurse's ability to provide holistic care and support patient well-being.

Correct Answer: D

Rationale: In this scenario, option D is the correct answer because the trachea shifting towards the opposite side of the neck indicates a tension pneumothorax, which is a life-threatening emergency requiring immediate intervention to prevent respiratory compromise and potential cardiac arrest. This finding suggests that there is increased pressure in the pleural space, causing the lung to collapse and pushing the trachea away from the affected side. Options A, B, and C are incorrect because they do not indicate a critical condition that warrants immediate action. While pain, drainage, and a pulse oximetry reading of 93% are important assessments post-thoracentesis, they do not signify a life-threatening complication like a tension pneumothorax. Educationally, it is crucial for nurses to understand and recognize the signs and symptoms of a tension pneumothorax, such as tracheal deviation, sudden respiratory distress, hypotension, and cyanosis. This knowledge is vital for prompt identification and intervention to prevent further deterioration in the client's condition. Nurses must be prepared to respond quickly and effectively in such emergent situations to ensure optimal patient outcomes.

Correct Answer: C

Rationale: The correct answer to the question is option C, "I'd like to hear about thoughts and feelings causing you to limit social activities." This response demonstrates therapeutic communication by acknowledging the client's feelings and actively listening to their concerns. By exploring the client's thoughts and emotions, the nurse can gain insight into the underlying reasons for the client's social withdrawal, which is crucial in addressing their needs effectively. Option A is incorrect because while support groups can be beneficial for individuals with COPD, it does not directly address the client's current feelings of not enjoying social activities. Option B is incorrect as prescribing an antianxiety agent should not be the first line of intervention without exploring the client's feelings and concerns further. It is important to address the root cause of the issue rather than simply prescribing medication. Option D is incorrect because while friends can indeed be a valuable support system for clients with chronic disorders, this response does not address the client's current feelings and the need to explore them further. In an educational context, it is essential for nurses to develop strong communication skills to effectively assess and address the holistic needs of their clients. By actively listening, acknowledging feelings, and exploring underlying emotions, nurses can provide client-centered care that promotes trust, understanding, and positive health outcomes. Therapeutic communication is a fundamental aspect of nursing practice and is key to building therapeutic relationships with clients.