A 51-year-old male client with pneumonia has undergone several days of antibiotic and respiratory treatment. Given the following assessment findings, mark whether they indicate that the treatment was effective or ineffective:
PaCO2 55 mm Hg on a blood gas
Rhonchi in the right lung
Oxygen saturation greater than 94%
Client ambulates without shortness of breath
Correct Answer : C,D
Choice A rationale:
PaCO2 55 mm Hg on a blood gas indicates ineffective treatment. Normal PaCO2 levels range from 35-45 mm Hg.
Elevated PaCO2 (hypercapnia) suggests that the lungs are not effectively removing carbon dioxide from the body. This can be due to various factors, including:
Incomplete resolution of pneumonia Airway obstruction
Impaired respiratory muscle function
Choice B rationale:
Rhonchi in the right lung indicates ineffective treatment.
Rhonchi are coarse, rattling sounds heard in the lungs during auscultation.
They are often associated with mucus accumulation in the airways, which can occur in pneumonia.
The presence of rhonchi suggests that inflammation and mucus production persist, despite antibiotic and respiratory therapy.
Choice C rationale:
Oxygen saturation greater than 94% indicates effective treatment. Normal oxygen saturation levels are typically 95% or higher.
A saturation of 94% or above suggests that the lungs are able to effectively oxygenate the blood. This is a positive sign that the pneumonia is responding to treatment.
Choice D rationale:
Client ambulates without shortness of breath indicates effective treatment. Shortness of breath (dyspnea) is a common symptom of pneumonia.
It occurs when the lungs are unable to provide enough oxygen to the body, leading to a feeling of breathlessness.
The ability to ambulate without shortness of breath suggests that the pneumonia has improved and that the lungs are functioning more effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.
Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.
Choice C rationale:
Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.
Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.
The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.
Choice D rationale:
Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.
While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.
Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.
Choice B rationale:
Tachypnea is the most likely condition indicated by the client's vital signs.
Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.
This can lead to rapid, shallow breathing, which is called tachypnea.
Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing
Wheezing Chest pain
Feeling short of breath
Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring
Cyanosis (a bluish tint to the skin)
Correct Answer is A
Explanation
Choice A rationale:
Famotidine is a histamine-2 receptor antagonist (H2RA) that decreases gastric acid secretion. It is often used to treat conditions such as ulcers, gastroesophageal reflux disease (GERD), and heartburn.
Bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole are all medications used in the treatment of H. pylori infection. However, these medications can interact with famotidine, potentially leading to decreased efficacy or increased side effects.
Therefore, it is important for the nurse to review the client's electronic medical record for any current or recent use of famotidine before administering the H. pylori treatment regimen. This will help to ensure the safety and effectiveness of the treatment.
Choice B rationale:
Loperamide is an antidiarrheal medication. It is not typically used in the treatment of H. pylori infection and is not known to interact with the medications used in this regimen.
Choice C rationale:
Aspirin is a salicylate medication that is often used to treat pain, fever, and inflammation. It can also be used to prevent blood clots. However, aspirin can interact with bismuth subsalicylate, potentially leading to increased risk of bleeding.
Therefore, it is important for the nurse to assess the client's risk of bleeding before administering the H. pylori treatment regimen if they are also taking aspirin.
Choice D rationale:
Ipratropium is a bronchodilator medication that is used to treat asthma and chronic obstructive pulmonary disease (COPD). It is not typically used in the treatment of H. pylori infection and is not known to interact with the medications used in this regimen.
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