Answer to Question 1
ANS: A
The patient's assessment indicates impending respiratory failure, and the nurse should prepare to assist with intubation and mechanical ventilation after notifying the health care provider. IV corticosteroids require several hours before having any effect on respiratory status. The patient will not be able to cough or deep breathe effectively. Documentation is not a priority at this time.
Answer to Question 2
ANS: C
Use of accessory muscle indicates that the patient is experiencing respiratory distress and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment but do not suggest that immediate treatment is required.