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

Answer and Explanation

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.

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Correct Answer is A, B, C, D, E

Explanation

A. Shake the canister 3 to 5 seconds vigorously.
Before each use, it's important to shake the MDI to ensure proper mixing of the medication.
B. Place her lips firmly around the mouthpiece.
Creating a tight seal around the mouthpiece ensures that the medication is delivered directly into the airways.
C. Inhale slowly over 3 to 5 seconds while pushing down on the canister.
While pressing down on the canister, the client should inhale slowly to allow the medication to reach the lungs.
D. Hold her breath for 10 seconds.
After inhaling the medication, holding the breath for 10 seconds allows for better absorption of the medication into the lungs.
E. Exhale slowly through pursed lips.
After holding the breath, exhaling slowly through pursed lips helps to fully exhale and ensures that the medication remains in the airways.

A. Identifying age-related changes B. Monitoring BG level C. Establishing the presence of an illness D. Improving hydration status

Correct Answer is D

Explanation

D. The priority focus in the acute management of hyperosmolar hyperglycemia is improving hydration status. Patients with HHS are severely dehydrated due to the osmotic diuresis caused by extremely high blood glucose levels. Rapid rehydration is critical to prevent shock, improve organ perfusion, and reduce blood glucose levels.
A. It's important to consider age-related changes in any patient but this is not the immediate priority in the acute management of hyperosmolar hyperglycemia. The primary concern is addressing the acute, life-threatening aspects of the condition.
B. Monitoring blood glucose levels is critical in managing hyperosmolar hyperglycemia. However, while it is essential to track the BG levels to guide insulin therapy and assess the response to treatment, it is not the immediate priority in terms of interventions needed to stabilize the patient initially.

C. Determining the underlying cause of hyperosmolar hyperglycemia, such as an infection or other illness, is important for comprehensive treatment. However, it is a secondary priority to stabilizing the patient’s current acute condition.

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A 33-year-old patient has pneumonia. When the nurse assesses this patient, which of the following data will receive the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

43. A nurse is reinforcing teaching about use of a metered-dose inhaler (MDI) with a client who has a new diagnosis of asthma. Identify the sequence the client should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all steps.)

Correct Answer is A, B, C, D, E

Explanation

A patient is admitted to the hospital with hyperosmolar hyperglycemia. The patient has a BG value of 987 mg/dL. Which is the priority focus while providing care?

Correct Answer is D

Explanation

A 33-year-old patient has pneumonia. When the nurse assesses this patient, which of the following data will receive the highest priority?

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