The nurse prepares to administer a new order for a non-rebreather mask. Which action is most important for the nurse to take?
Rationale:
The nurse should ensure the reservoir bag is inflated before placing the non-rebreather mask on the patient. This step guarantees that the patient receives a high concentration of oxygen with each breath by preventing room air from diluting the oxygen supply, thereby maximizing oxygen delivery and effectiveness of the therapy.
B: Set the oxygen flow rate to no more than 6 liters per minute risks inadequate inflation of the reservoir bag, reducing oxygen concentration and compromising the purpose of the non-rebreather mask’s high-flow oxygen delivery.
C: Assessing the patient’s ability to breathe independently is important but not the immediate priority for mask setup; ensuring the device functions correctly takes precedence before evaluating respiratory effort.
D: Monitoring changes in arterial blood gases is essential for ongoing assessment but is not the most critical initial action when preparing to administer oxygen via a non-rebreather mask.
A client reports a sore tongue and the inability to eat. What action by the nurse is best?
Rationale:
Teach the client about cobalamin therapy. Cobalamin (vitamin B12) deficiency often causes glossitis, leading to a sore tongue and difficulty eating. Educating the client on cobalamin therapy addresses the root cause, promoting symptom relief and preventing complications like pernicious anemia, which further impairs neurological and hematological functions. This intervention directly targets the underlying deficiency responsible for the client’s symptoms.
B: Order genetic testing for the client. Genetic testing does not provide immediate relief or directly address acute symptoms like a sore tongue or eating difficulties, making it an unnecessary initial action in this clinical scenario.
C: Encourage a high-fiber diet. A high-fiber diet primarily benefits gastrointestinal health and bowel function, but it does not alleviate symptoms of glossitis or address vitamin B12 deficiency causing tongue soreness.
D: Place the client on protective precautions. Protective precautions are typically used to prevent infection or injury in vulnerable patients, which does not correlate with managing symptoms of a sore tongue or difficulty eating related to nutritional deficits.
A patient receiving mechanical ventilation is at risk for ventilator-associated pneumonia (VAP). What is the best intervention?
Rationale:
Perform oral care with chlorhexidine.
Chlorhexidine oral care reduces the bacterial colonization in the oropharynx, lowering the risk of aspiration of contaminated secretions into the lungs. This intervention effectively decreases the incidence of ventilator-associated pneumonia by maintaining oral hygiene and preventing pathogenic growth, which is critical in patients on mechanical ventilation vulnerable to infections.
A: Administer prophylactic antibiotics increases antibiotic resistance risk and does not consistently prevent VAP, making it an unsuitable routine intervention.
C: Keep the patient sedated at all times raises complications like muscle weakness and does not directly reduce pneumonia risk.
D: Increase the frequency of suctioning may cause mucosal injury and discomfort without proven efficacy in preventing VAP.
This is the enzyme secreted by the pancrease that completes the protein digestion
Rationale:
Trypsin is the enzyme secreted by the pancreas that completes protein digestion. Trypsinogen, secreted by the pancreas, is activated into trypsin in the small intestine, where it breaks down proteins into smaller peptides, facilitating their absorption. This enzyme is crucial for protein digestion’s final stages, unlike other enzymes that target different substrates or have regulatory functions.
B: Enterokinase activates trypsinogen into trypsin but does not directly digest proteins. Its role is catalytic, initiating protease activity rather than completing protein digestion itself.
C: Enterogastrone is a hormone that inhibits gastric secretions and motility. It does not have enzymatic activity or directly participate in protein breakdown.
D: Amylase digests carbohydrates by breaking down starch into sugars, not proteins. It is unrelated to pancreatic protein digestion.
The nurse assesses a patient with pneumonia who is experiencing pleuritic chest pain. Which action should the nurse take?
Rationale:
Placing the patient in a side-lying position on the affected side helps reduce pleuritic chest pain by decreasing friction between the inflamed pleura and the chest wall. This position can alleviate discomfort and promote easier breathing, supporting lung expansion while minimizing pain caused by movement or deep inspiration in patients with pneumonia-related pleuritis.
A: Encouraging shallow breaths limits lung expansion, potentially worsening oxygenation and increasing the risk of atelectasis; it does not effectively address pain relief or promote adequate ventilation in pneumonia patients.
C: Administering morphine could depress respiratory drive and mask symptoms, complicating assessment and potentially causing respiratory depression in a patient with compromised pulmonary function.
D: Incentive spirometry is important for lung expansion but may exacerbate pleuritic pain during deep breaths and should be balanced with pain management strategies.
A client with COPD is prescribed a corticosteroid inhaler. What teaching point should the nurse emphasize?
Rationale:
Rinse your mouth after each use.
Rinsing the mouth after using a corticosteroid inhaler helps prevent oral thrush, a common side effect caused by steroid residue. It also reduces irritation and fungal infections in the mouth and throat. This simple step promotes oral hygiene and enhances overall treatment effectiveness by minimizing potential local side effects associated with inhaled corticosteroids.
A: Use the inhaler only when symptoms worsen. This advice overlooks the importance of consistent use to control inflammation and prevent exacerbations, not just treat acute symptoms.
C: Shake the inhaler only if symptoms persist. Shaking is necessary before every use to ensure proper medication delivery, not dependent on symptom presence.
D: Use the inhaler before a bronchodilator. Corticosteroids are generally used after bronchodilators to open airways first, enhancing steroid deposition and effectiveness.
A patient hospitalized with chronic obstructive pulmonary disease (COPD) is being discharged home on Oâ‚‚ therapy. Which instruction should the nurse include in the discharge teaching?
Rationale:
O₂ use can improve the patient's prognosis and quality of life. Long-term oxygen therapy in COPD patients reduces hypoxemia, decreases complications, and enhances physical activity tolerance, resulting in better survival rates and overall well-being. Proper oxygen use supports respiratory function and prevents disease progression, making it essential for managing chronic respiratory insufficiency in COPD patients at home.
A: Travel is not possible with the use of O₂ devices. Portable oxygen concentrators and tanks allow patients to travel safely, making this statement inaccurate and unnecessarily restrictive.
B: O₂ flow should be increased if the patient has more dyspnea. Increasing flow without medical guidance can cause CO₂ retention and respiratory depression, so flow adjustments require professional evaluation.
D: Storage of O₂ requires large metals tanks that each last 4 to 6 hours. Modern oxygen systems include smaller, portable tanks and concentrators, which provide more flexible oxygen delivery options than large metal tanks.
Which diagnosis is supported by a COPD patient's statement of inability to do anything for themselves?
Rationale:
Activity intolerance is supported by the patient's statement of inability to do anything for themselves. This diagnosis reflects a decreased capacity to perform physical activities due to fatigue, dyspnea, or weakness common in COPD patients. The patient's expressed limitation aligns with activity intolerance’s definition, indicating impaired physiological energy and endurance, which hinders self-care and daily functioning.
A: Deficient knowledge relates to lack of understanding or information, which does not explain the patient's expressed physical inability or fatigue in performing tasks.
C: Complicated grieving involves prolonged emotional distress following loss, unrelated to physical limitations or inability to perform activities.
D: Ineffective coping refers to maladaptive emotional or behavioral responses, not directly linked to physical inability or activity restrictions.
The nursing intervention that is appropriate for use with clients having an endotracheal tube is:
Rationale:
Providing room air is an appropriate nursing intervention for clients with an endotracheal tube. Ensuring adequate oxygenation without excessive oxygen concentration helps prevent oxygen toxicity and maintains optimal respiratory function. Room air supports lung tissue health and minimizes complications, promoting patient safety and comfort during mechanical ventilation or tube placement, which is critical in respiratory management.
B: Communicating frequently with the client is challenging due to the inability to speak with an endotracheal tube, limiting effectiveness as a primary nursing intervention in this context.
C: Rapidly assessing nasal and oral mucosa for redness and irritation is important but not prioritized as an intervention; it is more of an ongoing assessment rather than a direct nursing action.
D: None of these dismisses valid interventions; providing room air is a recognized and essential nursing practice for patients with an endotracheal tube, making this option invalid.
Which assessment finding in a patient who has received omalizumab (Xolair) is most important to report immediately to the health care provider?
Rationale:
Flushing and dizziness is the most important assessment finding to report immediately to the health care provider. This could indicate a severe allergic reaction or anaphylaxis, a known potential adverse effect of omalizumab. Prompt recognition and intervention are critical to prevent respiratory compromise or cardiovascular collapse. Immediate reporting facilitates urgent management and ensures patient safety during treatment.
A: Pain at injection site represents a common, localized reaction often self-limiting and less urgent, without systemic implications requiring immediate intervention or reporting to the healthcare provider.
C: Peak flow reading 75% of normal indicates mild to moderate airway obstruction but is not as urgent as systemic allergic symptoms needing immediate attention.
D: Respiratory rate 24 breaths/minute is slightly elevated but within a range that typically does not demand immediate reporting compared to signs of hypersensitivity or anaphylaxis.
Which of the following would be a contraindication to inserting a nasopharyngeal airway?
Rationale:
A motor vehicle collision (MVC) with head trauma would be a contraindication to inserting a nasopharyngeal airway. Head trauma raises the risk of basal skull fractures, where inserting a nasopharyngeal airway could cause intracranial placement, leading to severe complications. Thus, avoiding this airway in such trauma cases is critical to prevent exacerbating injuries or causing further neurological damage.
A: Patient with an INR of 1.7 This patient has a mildly elevated bleeding risk but no direct contraindications for nasopharyngeal airway insertion. Careful monitoring suffices without outright avoidance.
B: Semi conscious patient Semi-conscious status often necessitates airway support, making nasopharyngeal airway insertion appropriate, not contraindicated, to maintain patency and prevent obstruction.
D: Deviated nasal septum While a deviated septum may complicate insertion, it generally does not contraindicate nasopharyngeal airway use and can be managed with careful technique and assessment.
A nurse is caring for a patient with a history of stroke who is unable to speak. What is the priority nursing action?
Rationale:
Reposition the patient to prevent aspiration.
This action is paramount because patients with stroke-related speech impairment often have compromised swallowing and airway protection, increasing aspiration risk. Proper positioning minimizes aspiration pneumonia, a leading cause of morbidity. Prioritizing airway safety ensures optimal respiratory function and prevents complications, making it the immediate focus before other rehabilitative or supportive interventions.
A: Perform a swallowing assessment. This is essential but follows ensuring airway safety; it is not the immediate priority.
B: Assist the patient with physical therapy. Physical therapy supports recovery but does not address the urgent risk of aspiration in this context.
D: Administer a short-acting beta-agonist. This medication treats bronchospasm, unrelated to stroke-induced speech or aspiration issues here.
A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?
Rationale:
The patient's white blood cell (WBC) count is 9000/µL. A normal WBC count indicates that the infection is resolving, as elevated levels typically signify active infection or inflammation. After three days of IV antibiotics, a WBC count returning to normal demonstrates effective treatment response and improved immune status, reflecting diminished bacterial activity and reduced systemic inflammatory response.
A: Bronchial breath sounds are heard at the right base. Persistent bronchial breath sounds usually suggest ongoing consolidation in the lung, indicating unresolved pneumonia rather than improvement.
B: The patient coughs up small amounts of green mucus. Producing green mucus often points to continued infection or inflammation, which means the pneumonia may not be fully treated yet.
D: Increased tactile fremitus is palpable over the right chest. Increased tactile fremitus typically signals lung consolidation, reflecting active pneumonia rather than successful treatment or recovery.
What is the most effective means for ensuring compliance with TB treatment?
Rationale:
Providing a daily meal is the most effective means for ensuring compliance with TB treatment. This approach addresses patients’ nutritional needs and incentivizes adherence by reducing barriers such as food insecurity, which often hinders consistent medication intake. Providing meals fosters trust and routine, making patients more likely to follow through with their treatment plans consistently and improve health outcomes.
A: Providing written instructions alone lacks direct support and motivation, making it less impactful on adherence, especially when patients face literacy or comprehension challenges.
C: Monthly check-ins provide infrequent oversight, insufficient to maintain continuous adherence or promptly address side effects and obstacles during the lengthy TB treatment.
D: Self-administration depends heavily on patient discipline without external accountability, often resulting in inconsistent medication intake and increased risk of treatment failure or resistance.
There is a continuous bubbling in the water sealed drainage system with suction. And oscillation is observed. As a nurse, what should you do?
Rationale:
Continuous bubbling in the water sealed drainage system with suction and oscillation is considered normal. This happens because suction creates negative pressure that causes bubbling and oscillation, indicating the system is functioning correctly and air is not leaking into the pleural space. Monitoring ensures no other complications arise while maintaining system integrity.
B: Notify the physician is unnecessary immediately because continuous bubbling with oscillation does not indicate an emergency or complication needing urgent medical intervention when suction is applied properly.
C: Check for tube leak is unwarranted since continuous bubbling and oscillation in a sealed system under suction typically signify proper function, not an air leak, which would show different signs like subcutaneous emphysema.
D: Prepare a petrolatum gauze dressing is irrelevant here because bubbling and oscillation do not imply a wound or air leak at the insertion site requiring airtight dressing preparation.
A patient with a pleural effusion is scheduled for a thoracentesis. Which action should the nurse take to prepare the patient for the procedure?
Rationale:
Position the patient sitting up on the side of the bed. This position allows optimal access to the posterior pleural space for fluid removal during thoracentesis, improving safety and effectiveness. It also helps the patient remain still and comfortable, minimizing the risk of injury or complications during needle insertion, which is crucial for a successful procedure.
A: Start a peripheral IV line to administer sedatives. Peripheral IV placement is not routinely necessary before thoracentesis unless sedation or emergency medication administration is anticipated, so it is not a standard preparatory step for all patients.
C: Obtain a collection device to hold 3 liters of pleural fluid. Collecting that volume at once is unsafe; typically, less than 1.5 liters are removed to avoid complications like re-expansion pulmonary edema.
D: Remind the patient not to eat or drink anything for 6 hours. Fasting is generally not required prior to thoracentesis because it is a minimally invasive procedure without general anesthesia.
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?
Rationale:
The most effective action is to accomplish the patient teaching just before the scheduled discharge. Teaching close to discharge ensures information is fresh in the patient’s mind, promoting better retention and adherence to instructions. Timing education near discharge helps address immediate concerns, reduces forgetfulness, and encourages the patient to apply learned self-care measures promptly after leaving the hospital environment.
A: Having the patient repeat instructions immediately increases engagement but does not guarantee long-term retention or compliance if done too early before discharge.
B: Caregiver presence supports understanding but may not improve patient compliance if teaching is not timed effectively near discharge.
D: Caregiver involvement is valuable, yet it lacks impact without proper timing of education close to patient discharge.
Which finding in a patient with chronic bronchitis requires immediate action?
Rationale:
Oxygen saturation of 85% on room air requires immediate action. This finding indicates significant hypoxemia, which can lead to tissue hypoxia and organ dysfunction if not promptly addressed. Chronic bronchitis patients often have compromised lung function, so low oxygen saturation necessitates urgent intervention such as supplemental oxygen or further evaluation to prevent respiratory failure and complications.
A: Respiratory rate of 22 breaths per minute represents a mildly elevated rate, often seen in chronic bronchitis, but does not indicate immediate distress or critical hypoxia requiring urgent treatment.
C: Frequent productive cough with clear sputum is typical in chronic bronchitis and reflects mucus clearance rather than an acute emergency needing immediate action.
D: Barrel-shaped chest is a physical sign of chronic lung disease adaptation, not an acute condition demanding urgent medical intervention.
The nurse teaches a patient about using a dry powder inhaler. Which statement indicates effective learning?
Rationale:
Effective learning is indicated by the statement, "I should inhale quickly and deeply."
Inhaling quickly and deeply is essential for dry powder inhalers because it helps to disperse the powder properly into the lungs, ensuring optimal medication delivery and effectiveness. Unlike metered-dose inhalers, dry powder inhalers rely on the patient’s inspiratory effort, making this technique critical for therapeutic success.
A: Shaking is unnecessary for dry powder inhalers as they do not contain propellants or require mixing, unlike metered-dose inhalers.
C: Spacers are designed for metered-dose inhalers, not dry powder inhalers, so attaching one is irrelevant for this device.
D: Exhaling forcefully after inhaling the medication would expel the drug from the lungs, reducing its effectiveness and defeating the purpose of inhalation.
A patient who has a history of chronic obstructive pulmonary disease (COPD) was hospitalized for increasing shortness of breath and chronic hypoxemia (SaO2 levels of 89% to 90%). In planning for discharge, which action by the nurse will be most effective in improving compliance with discharge teaching?
Rationale:
Having the patient's caregiver present during the teaching will be most effective in improving compliance with discharge instructions.
Caregiver involvement ensures additional support and reinforcement of instructions, especially for patients with chronic conditions like COPD who may have cognitive or physical limitations. Caregivers can help clarify information, assist with medication management, and provide ongoing encouragement, which enhances understanding and adherence to the discharge plan, ultimately improving patient outcomes.
A: Have the patient repeat the instructions immediately after teaching limits retention since immediate repetition doesn’t guarantee long-term understanding or compliance.
B: Accomplishing teaching just before discharge may overwhelm the patient, reducing absorption of critical information necessary for effective self-care.
D: Accomplishing teaching just before discharge duplicates option B and shares its shortcoming of poor timing for optimal learning and retention.
A nurse obtains the health history of a client who is newly admitted to the medical unit. Which statement by the client would alert the nurse to the presence of edema?
Rationale:
The statement "My shoes fit tighter by the end of the day" alerts the nurse to the presence of edema. Edema causes fluid accumulation in tissues, often leading to swelling, especially in the feet and ankles, which makes shoes feel tighter. This symptom directly indicates abnormal fluid retention, unlike the other options that do not reflect swelling or fluid imbalance.
A: I wake up to go to the bathroom at night reflects nocturia, which relates to urinary patterns, not swelling or fluid retention indicative of edema.
C: I seem to be feeling more anxious lately describes emotional state changes, unrelated to physical signs of fluid buildup or tissue swelling characteristic of edema.
D: I drink at least eight glasses of water a day indicates hydration habits but does not signal swelling or fluid accumulation that would suggest edema presence.
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
Rationale:
Blood cultures from two sites should be obtained first to identify the causative organism before starting antibiotics. This step ensures targeted therapy and helps prevent antibiotic resistance. Early blood cultures guide effective treatment and improve patient outcomes in sepsis management, making it the priority over imaging, medication, or symptom relief.
A: Chest x-ray via stretcher delays critical diagnostic confirmation of infection source; immediate blood cultures take precedence to guide timely antibiotic therapy in sepsis.
C: Ciprofloxacin (Cipro) 400 mg IV should not precede blood cultures since administering antibiotics beforehand may alter culture results and hinder pathogen identification.
D: Acetaminophen (Tylenol) rectal suppository addresses fever symptomatically but does not treat or diagnose the underlying infection, making it a lower priority than obtaining blood cultures.
The nurse is caring for a client with acute bronchitis. Which instruction is most important for preventing complications?
Rationale:
Drinking at least 8 glasses of water daily is most important for preventing complications in acute bronchitis.
Adequate hydration thins mucus secretions, facilitating easier expectoration and preventing mucus plugs that can lead to infection or airway obstruction. Maintaining fluid intake supports respiratory function and helps clear the bronchial passages, reducing the risk of secondary bacterial infections and promoting faster recovery in acute bronchitis cases.
A: Avoid humidifiers to reduce allergens ignores the benefits of moisture in loosening mucus, which aids expectoration and respiratory comfort, making this advice counterproductive in managing bronchitis symptoms.
C: Engage in light exercise to promote lung expansion could exacerbate symptoms or fatigue during acute illness, potentially worsening respiratory distress rather than safely improving lung function.
D: Use over-the-counter cough suppressants as needed might inhibit productive coughing, which is essential for clearing mucus, and could inadvertently increase the risk of retained secretions and complications.
The nurse receives a change-of-shift report. Which patient should the nurse assess first?
Rationale:
The nurse should assess the patient with asthma who has wheezing after albuterol treatment first. Wheezing after treatment indicates persistent airway obstruction and potential respiratory distress, requiring immediate evaluation to prevent deterioration. This patient’s condition suggests active bronchospasm or inadequate response to therapy, making timely assessment critical to adjust treatment and ensure airway patency.
A: A patient with bronchitis who has a weak cough is less urgent as weak cough usually indicates mucus retention but does not immediately threaten airway patency or oxygenation.
B: A patient with emphysema who has an O2 saturation of 90% is stable enough for routine monitoring since 90% is borderline but not critically low.
D: A patient with pneumonia who has crackles in the right lung base shows signs of infection but lacks acute respiratory distress, so immediate assessment is less urgent.
A student observes a nurse instilling a small amount of saline into a tracheostomy tube before suctioning. What should the student discuss with the nurse?
Rationale:
Saline is no longer recommended for routine suctioning.
Using saline routinely before suctioning can increase the risk of infection, cause patient discomfort, and does not improve secretion removal. Current guidelines advise against this practice to promote safer, evidence-based care and avoid unnecessary complications during tracheostomy suctioning procedures. The student should address this outdated technique with the nurse.
A: a description of how the nurse is carrying out the skill Observing the technique does not address the potential harm or guideline changes related to saline use and misses the opportunity for patient safety discussion.
C: nothing; the nurse has been doing this for years Accepting long-standing practice ignores updated clinical evidence and compromises patient safety by perpetuating potentially harmful suctioning methods.
D: compliments for carrying out the procedure skillfully Praising the nurse overlooks the outdated practice of saline instillation and fails to encourage adherence to current best practices and patient safety standards.
A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?
Rationale:
Instruct the patient about pancreatic enzyme replacements. Pancreatic enzyme replacement is crucial in cystic fibrosis management to aid digestion and nutrient absorption, as CF commonly causes pancreatic insufficiency. Proper enzyme use helps prevent malnutrition and supports overall health, addressing a fundamental aspect of CF care rather than focusing solely on respiratory symptoms or diagnostic testing.
A: Schedule a sweat chloride test. This test diagnoses CF but does not address acute symptoms like increased dyspnea or ongoing management needs. It is irrelevant during hospitalization for symptom exacerbation.
B: Arrange for a hospice nurse visit. Hospice care targets end-of-life support, inappropriate for a young adult with CF experiencing reversible respiratory distress needing active treatment.
C: Perform chest physiotherapy every 4 hours. While chest physiotherapy aids mucus clearance, the frequency should be individualized; routine 4-hour intervals may not be appropriate without assessment of patient condition or preference.
A patient with chronic obstructive pulmonary disease (COPD) is prescribed theophylline. Which finding would be most concerning?
Rationale:
A heart rate of 112 beats per minute would be most concerning in a patient prescribed theophylline. Theophylline toxicity often manifests as cardiovascular disturbances, including tachycardia, which can escalate to serious arrhythmias. Monitoring heart rate is critical because elevated rates indicate potential toxicity requiring prompt intervention to prevent life-threatening complications, unlike less severe side effects or therapeutic drug levels.
A: Nausea and vomiting typically represent mild side effects of theophylline and are not immediately dangerous, often manageable with dosage adjustments and supportive care, lacking the urgency of cardiovascular symptoms.
C: Mild hand tremors are common, usually benign side effects associated with theophylline’s stimulant properties, not indicative of severe toxicity or requiring immediate medical action.
D: Theophylline level of 15 mcg/mL remains within the therapeutic range (10-20 mcg/mL), suggesting effective dosing without toxicity, thus not an alarming finding in this context.
The nurse is providing education to a client with asthma. What should the nurse emphasize to prevent asthma attacks?
Rationale:
Using a peak flow meter to monitor lung function helps detect early signs of asthma exacerbation, allowing timely intervention to prevent attacks. Regular monitoring provides objective data on airway obstruction, enabling clients to adjust medications and avoid triggers effectively. This proactive approach reduces the frequency and severity of asthma episodes, enhancing overall disease management and maintaining better respiratory health.
A: Avoiding exercise during cold weather limits physical activity unnecessarily; exercise often benefits asthma control unless cold air specifically triggers symptoms, making this advice overly restrictive and not universally preventive.
B: Taking short-acting bronchodilators daily can lead to overuse and tolerance, rather than preventing attacks; they are intended for relief during acute symptoms, not routine prevention.
C: Limiting fluid intake does not prevent mucus buildup; hydration actually helps thin mucus, facilitating clearance and reducing airway obstruction in asthma management.
The nurse admits a patient who has a diagnosis of an acute asthma attack. Which statement indicates that the patient may need teaching regarding medication use?
Rationale:
The statement "I've been using my albuterol inhaler more frequently over the last 4 days" indicates the patient may need teaching regarding medication use. Frequent albuterol use signals worsening asthma control and potential overuse of a rescue inhaler, necessitating education on proper management and when to seek further medical help to prevent exacerbations and complications.
A: "I have not had any acute asthma attacks during the past year." This statement reflects stable asthma control, suggesting the patient understands their condition and medication effectiveness, making it unrelated to medication misuse or misunderstanding.
B: "I became short of breath an hour before coming to the hospital." This reports a symptom of an acute attack, not medication usage, indicating awareness of asthma exacerbation rather than incorrect medication application or understanding.
C: "I've been taking Tylenol 650 mg every 6 hours for chest wall pain." This indicates symptom management unrelated to asthma medication, showing no confusion about asthma drug use but addressing pain, which is separate from inhaler misuse.
What is the priority nursing action for a patient presenting with possible pulmonary embolism?
Rationale:
Applying oxygen and elevating the head of the bed is the priority nursing action for a patient presenting with possible pulmonary embolism. This intervention improves oxygenation, reduces respiratory distress, and supports ventilation while further assessment and treatments are prepared, addressing the immediate life-threatening hypoxia associated with pulmonary embolism.
A: Administer prescribed anticoagulants delays immediate respiratory support, which is critical before medication administration to stabilize oxygen levels and prevent worsening hypoxia in pulmonary embolism.
C: Prepare for a chest x-ray postpones urgent oxygen therapy, which is essential for maintaining adequate oxygenation in acute pulmonary embolism cases.
D: Notify the healthcare provider immediately overlooks the necessity of immediate oxygen support and positioning to alleviate respiratory distress and improve patient stability.