The nurse is assessing the skin of a patient diagnosed with psoriasis.
The nurse understands that which characteristic is associated with this skin disorder?

Choice A rationale

While IV access is important for fluid resuscitation and medication administration, establishing an airway and ensuring adequate oxygenation are the most immediate priorities. The patient's oxygen saturation is critically low at 90%, indicating severe hypoxemia. Following the ABCs of resuscitation (Airway, Breathing, Circulation), addressing the breathing problem takes precedence over initiating an IV line.

Choice B rationale

A chest X-ray is a diagnostic tool that provides crucial information about the underlying pathology, such as a pneumothorax. However, obtaining a chest X-ray takes time and should not delay immediate, life-saving interventions. The patient's respiratory distress and low oxygen saturation require immediate action to support oxygenation, as delayed intervention can lead to respiratory failure and cardiac arrest.

Choice C rationale

The patient's respiratory rate of 38 breaths/min and oxygen saturation of 90% indicate severe respiratory distress and hypoxemia. Administering high-flow oxygen directly addresses the life-threatening lack of oxygen, improving tissue oxygenation and supporting cellular function. This is the most critical first step in managing a patient with compromised breathing, following the ABCs of resuscitation.

Choice D rationale

Preparing for a chest tube insertion is a vital intervention for a suspected pneumothorax, which is suggested by the absent breath sounds. However, this is a procedural step that follows the initial stabilization of the patient's breathing. The immediate priority is to provide oxygen to prevent further desaturation, while simultaneously preparing for definitive treatment. The preparation should happen concurrently with oxygen administration, not before it.

Choice A rationale

Pursed-lip breathing is a technique used to slow down the breathing rate and facilitate a more complete exhalation, primarily beneficial for patients with obstructive lung diseases like COPD. It does not provide the positive intrathoracic pressure necessary to prevent air from entering the pleural space during a chest tube removal.

Choice B rationale

Lying flat and breathing deeply does not create the necessary positive pressure within the pleural cavity. This action would not prevent air from being sucked into the chest cavity, leading to a potential pneumothorax. The patient needs to increase intrathoracic pressure to seal the site.

Choice C rationale

The Valsalva maneuver, which involves taking a deep breath, holding it, and bearing down, increases intrathoracic pressure. This positive pressure helps to prevent air from rushing back into the pleural space when the chest tube is removed, thus minimizing the risk of a tension pneumothorax.

Choice D rationale

Rapid breathing, or hyperventilation, would decrease intrathoracic pressure and could potentially cause more air to be drawn into the pleural space upon removal of the chest tube. This action could lead to a tension pneumothorax. *.