Which patient requires the nurse's immediate attention?

Correct Answer: C

Rationale: The correct answer is C because a patient with asthma using accessory muscles to breathe indicates severe respiratory distress and imminent respiratory failure. Immediate intervention is needed to prevent further complications. Choice A is incorrect because mild dyspnea in a patient with chronic bronchitis may not warrant immediate attention. Choice B is incorrect because although an oxygen saturation of 88% is concerning, it may not always require immediate attention compared to a patient in severe distress like in Choice C. Choice D is incorrect as mild discomfort at the chest tube site may not be as urgent as a patient in respiratory distress.

Correct Answer: B

Rationale: The correct answer is B: Oxygen saturation of 88% on room air. This finding indicates severe hypoxemia, which is a medical emergency requiring immediate intervention to prevent hypoxia-related complications. Hypoxemia can lead to tissue damage and organ dysfunction. Immediate follow-up may involve providing supplemental oxygen and assessing the patient's respiratory status. Choice A: Temperature of 101°F is slightly elevated but not an immediate concern in the context of pneumonia treatment. Choice C: Productive cough with yellow sputum is a common symptom of pneumonia and does not require immediate follow-up unless accompanied by other concerning symptoms. Choice D: Crackles in both lung bases are expected in pneumonia and do not necessitate immediate action unless associated with respiratory distress.

Correct Answer: B

Rationale: The correct interpretation is uncompensated respiratory acidosis (Choice B). Step-by-step rationale: 1. pH is low (acidosis): Indicates an acid-base imbalance. 2. PaCO2 is high (55 mm Hg): Indicates respiratory acidosis. 3. HCO3- is within normal range (24 mEq/L): Indicates no compensation by the kidneys. Therefore, the patient is experiencing respiratory acidosis without compensatory metabolic changes. Other choices are incorrect: A: Metabolic acidosis: HCO3- is within normal range. C: Partially compensated metabolic acidosis: PaCO2 is high, not low. D: Compensated respiratory alkalosis: pH is low, indicating acidosis.

Correct Answer: B

Rationale: The correct answer is B: Provide oxygen therapy as needed. In a patient with a pulmonary embolism, ensuring adequate oxygenation is the priority to prevent hypoxia and tissue damage. Oxygen therapy helps improve oxygen saturation levels, reducing the workload on the heart and lungs. Administering anticoagulants (Choice A) is important but not the immediate priority. Positioning in high Fowler's (Choice C) may help with breathing but doesn't address immediate oxygen needs. Notifying the healthcare provider (Choice D) is essential but not the immediate action needed to stabilize the patient.

Correct Answer: C

Rationale: The correct answer is C because a decrease in white blood cell count indicates a reduction in infection. This is a key indicator of the effectiveness of antibiotic treatment for pneumonia. A: Bronchial breath sounds indicate consolidation, which is not necessarily indicative of improvement. B: Green mucus suggests ongoing infection rather than improvement. D: Increased tactile fremitus can be present in pneumonia and may not necessarily change with treatment efficacy.