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
Explanation
B. Orange juice is highly acidic and can irritate the esophagus, leading to increased heartburn symptoms. Regular consumption of acidic beverages like orange juice can exacerbate GERD symptoms, making this a likely contributing factor to the client's heartburn.
A. Consuming low-fat meats is generally not a contributing factor to heartburn. Low-fat meats are less likely to cause reflux compared to high-fat foods, which can relax the lower esophageal sphincter and increase the risk of acid reflux.
C. Eating dinner early in the evening is generally recommended for managing GERD. This practice allows more time for the stomach to empty before lying down to sleep, reducing the likelihood of acid reflux during the night.
D. Sleeping on a large wedge-style pillow is also generally recommended for managing GERD. Elevating the head and upper body during sleep can help prevent acid from flowing back into the esophagus.
Correct Answer is D
Explanation
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.
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