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 A
Explanation
A. Diabetes can lead to damage of blood vessels throughout the body, both large and small. Complications can affect various organs and systems, including the heart, kidneys, eyes, and nerves. Damage to both large vessels (macrovascular complications) and tiny vessels (microvascular complications) contributes to the diverse range of complications associated with diabetes.
B. Both type 1 and type 2 diabetes increase the risk of long-term complications, but the specific risks and patterns of complications may differ between the two types. While individuals with type 1 diabetes may face challenges in achieving tight glycemic control due to the complete absence of endogenous insulin production, tight control can significantly reduce the risk of complications in both type 1 and type 2 diabetes.
C. Lower HbA1c levels indicate better overall glycemic control and are associated with reduced risk of long-term complications. However, achieving tight glycemic control should be balanced with the risk of hypoglycemia and individual patient factors.
D. Hypoglycemia can also lead to increased risk of cardiovascular events and mortality in individuals with diabetes. Therefore, it is important to balance glycemic control to minimize the risk of hypoglycemia while also reducing the risk of hyperglycemia-related complications.
Correct Answer is A
Explanation
A. This range is generally considered acceptable for most patients with COPD. It provides a balance between ensuring adequate oxygenation while avoiding the risk of oxygen toxicity. Oxygen saturation levels within this range can help alleviate symptoms of hypoxemia without causing hyperoxia.
B. Oxygen saturation levels below 90% can lead to significant hypoxemia and exacerbate respiratory distress in individuals with COPD. Maintaining oxygen saturation levels above 90% is typically recommended to prevent complications associated with hypoxemia.
C. This range is appropriate for some patients but it may not be ideal for all patients with COPD. Oxygen saturation levels at the higher end of this range (e.g., 100%) can increase the risk of oxygen toxicity in patients with COPD who retain carbon dioxide (CO2) due to their chronic respiratory condition.
D. Oxygen saturation levels within this range help to balance the need for oxygen supplementation with the risk of hyperoxia and oxygen toxicity. However, individual patient factors, such as the severity of COPD, baseline oxygen saturation levels, and comorbidities, should be considered when determining the target range for oxygen saturation.
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