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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Leaving the dressing off would expose the wound to air and potential contamination, which could delay healing and increase the risk of infection.

While consulting with the healthcare provider is always an option, it's not necessary in this case as the nurse has the knowledge and skills to select an appropriate dressing.

Additionally, leaving the wound uncovered could cause pain and discomfort to the patient, as well as potentially disrupt the delicate granulation tissue that has already formed.

Choice C rationale:

Increasing the frequency of dressing changes could disrupt the healing process and irritate the wound bed.

It's generally recommended to change dressings only as often as necessary to keep the wound clean and moist. Excessive dressing changes can also be costly and time-consuming for both the patient and the healthcare provider. Choice D rationale:

Transparent dressings are not ideal for stage 3 pressure injuries with significant granulation tissue. These dressings are more suitable for wounds with minimal exudate and that are not actively healing. Transparent dressings can also adhere to the wound bed, causing pain and trauma upon removal.

Choice B rationale:

Hydrocolloidal gel dressings are a good choice for stage 3 pressure injuries with granulation tissue because they: Provide a moist wound environment, which promotes healing.

Absorb exudate, which helps to prevent maceration of the surrounding skin. Form a protective barrier over the wound, which helps to prevent infection.

Are comfortable for the patient and can be left in place for several days.

A. Pneumonia B. Tuberculosis C. Bronchitis D. Pulmonary Embolism

Correct Answer is A

Explanation

Choice A rationale:

Pneumonia is the most likely diagnosis given the rapid development of pulmonary infiltrates within a 24-hour period. Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi. It typically presents with symptoms such as fever, cough, shortness of breath, and chest pain. The presence of pulmonary infiltrates on imaging studies, such as a chest X-ray, is a key diagnostic feature of pneumonia.

The distribution of the infiltrates, involving the lower lobes with a predominance on the right side, is also consistent with pneumonia. This is because the lower lobes are more susceptible to pneumonia due to their anatomy and gravity.

The absence of active processes on Day 1 makes other diagnoses less likely. For example, tuberculosis typically develops more slowly over weeks or months, and bronchitis usually does not cause pulmonary infiltrates.

Pulmonary embolism can cause pulmonary infiltrates, but it would typically be associated with other symptoms such as sudden onset of shortness of breath, chest pain, and tachycardia.

Choice B rationale:

Tuberculosis is a chronic infection that typically develops slowly over weeks or months. It is less likely to cause rapid development of pulmonary infiltrates as seen in this case.

Tuberculosis often involves the upper lobes of the lungs, and it may be associated with other symptoms such as fever, night sweats, and weight loss.

Choice C rationale:

Bronchitis is an inflammation of the bronchi, the large airways that carry air to the lungs. It typically causes a cough, but it does not usually cause pulmonary infiltrates.

Bronchitis is often caused by a virus, and it usually resolves on its own within a few weeks.

Choice D rationale:

Pulmonary embolism is a blockage of a pulmonary artery, one of the blood vessels that carries blood to the lungs. It can cause pulmonary infiltrates, but it would typically be associated with other symptoms such as sudden onset of shortness of breath, chest pain, and tachycardia.

Pulmonary embolism is often caused by a blood clot that travels from a vein in the leg to the lungs.

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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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a routine dressing change for a patient with a stage 3 pressure injury that is red with significant granulation.The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is B

Explanation

Patient Data shows that on Day 1, there were no active processes.On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side.What is the likely diagnosis?

Correct Answer is A

Explanation

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