A 33-year-old patient has pneumonia. When the nurse assesses this patient, which of the following data will receive the highest priority?
presence of hiccups, amount of sweating BP
capillary refill, amount of sputum, trembling
size of pupil, presence of sneezing, location of pain
restlessness, chest wall movement, color of nails
The Correct Answer is D
D. Restlessness can be an early sign of hypoxia. Chest wall movement provides information about the effort and effectiveness of breathing, and the color of the nails can indicate cyanosis, which is a sign of poor oxygenation. These data points are directly related to assessing respiratory status and the severity of pneumonia.
A. Hiccups, sweating, and blood pressure can provide useful information about the patient's condition, they do not directly indicate the severity of respiratory distress or oxygenation status. Hiccups can be a sign of diaphragmatic irritation, sweating can indicate fever or infection, and blood pressure is a general vital sign but not specific to respiratory function.
B. Capillary refill can provide information about peripheral perfusion, and the amount of sputum can be relevant to respiratory status, particularly in an infection like pneumonia. Trembling might indicate fever or anxiety but is less directly related to respiratory status compared to other signs.
C. Pupil size and sneezing are not directly related to respiratory function in pneumonia. Pain location could be relevant if it indicates pleuritic pain, but this set of data does not provide the most critical information for assessing respiratory function and oxygenation in a patient with pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
B. Bronchodilators are medications commonly used to relieve bronchospasm and improve airflow in patients with COPD. They work by relaxing the muscles around the airways, making it easier to breathe. Providing bronchodilators as prescribed can help alleviate difficulty breathing and improve the patient's respiratory function.
D. Smoking cessation is essential for patients with COPD as smoking is the leading cause of the disease and can exacerbate respiratory symptoms. Quitting smoking can slow the progression of COPD, reduce the frequency and severity of exacerbations, and improve overall lung function.
E. Corticosteroids are anti-inflammatory medications commonly used to reduce airway inflammation and control exacerbations in patients with COPD. They can help improve breathing and reduce the severity of respiratory symptoms during acute exacerbations.
A. Offering small frequent meals can help reduce the sensation of fullness and bloating, which can sometimes occur in patients with COPD due to increased abdominal pressure from compromised respiratory function. However, this is not specific to COPD.
C. Weaning from oxygen should be done cautiously and under the guidance of healthcare providers but not in the state of difficulty in breathing. Oxygen therapy is often necessary for patients with COPD who experience difficulty breathing, especially during acute exacerbations. Therefore, weaning from oxygen may be appropriate once the patient's respiratory status stabilizes and oxygen saturation levels improve.
Correct Answer is C
Explanation
C. Elevating the head of the bed can help reduce nighttime GERD symptoms. By elevating the head of the bed by about 6 to 8 inches (15 to 20 centimeters), gravity helps prevent stomach acid from refluxing into the esophagus while the individual is lying down. This position can alleviate symptoms such as heartburn, regurgitation, and coughing during sleep.
A. Alcohol consumption, especially before bedtime, can exacerbate GERD symptoms. Alcohol relaxes the lower esophageal sphincter (LES), allowing stomach acid to reflux into the esophagus more easily.
B. Sleeping on the stomach with the head flat can worsen GERD symptoms. This position can increase pressure on the stomach and promote reflux of stomach acid into the esophagus. Sleeping on the stomach is generally not recommended for individuals with GERD.
D. Eating a large meal or having a snack shortly before bedtime can increase the likelihood of GERD symptoms during sleep. It's generally recommended to avoid eating large meals or heavy snacks close to bedtime. Instead, individuals with GERD should aim to finish eating at least 2 to 3 hours before lying down to sleep.
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