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 D
Explanation
Choice A rationale:
Incorrect. Open-angle glaucoma is not characterized by an abnormally small angle.
The angle in open-angle glaucoma is open, but the drainage system is not working properly. Therefore, restoring a smaller angle would not be an effective treatment goal.
Choice B rationale:
Incorrect. Eye drops used to treat open-angle glaucoma are not typically used for pain control.
While some individuals may experience mild discomfort associated with elevated eye pressure, pain is not a common symptom of open-angle glaucoma.
Additionally, eye drops used to treat glaucoma do not have anti-inflammatory properties to address swelling.
Choice C rationale:
Incorrect. While reducing excess eye pressure is an important initial goal of treatment, long-term management of open-angle glaucoma requires ongoing maintenance of normal eye pressure.
Simply reducing pressure temporarily is not sufficient to prevent vision loss.
Choice D rationale:
Correct. The primary goal of treatment for open-angle glaucoma is to maintain normal eye pressure over the long term. This is because elevated eye pressure can damage the optic nerve, leading to vision loss.
Eye drops are often used to lower eye pressure, and they typically need to be used for life to prevent vision loss.
Correct Answer is C
Explanation
Choice A rationale:
Diminished breath sounds in the right lung: This finding suggests that there is still some inflammation or fluid in the right lung, which is not consistent with fully effective treatment. Normal breath sounds should be clear and equal bilaterally.
PaCO2 55 mm Hg on a blood gas: This finding is slightly elevated, indicating that the patient may be having some difficulty clearing carbon dioxide from the lungs. A normal PaCO2 is 35-45 mm Hg.
Rhonchi in the right lung: Rhonchi are a type of abnormal breath sound that is caused by secretions in the airways. This finding suggests that there is still some inflammation or infection in the right lung.
Choice B rationale:
Oxygen saturation greater than 94%: This finding is within the normal range and indicates that the patient is getting enough oxygen.
Client ambulates without shortness of breath: This finding is a positive sign that the patient's respiratory status is improving. Symmetric chest expansion: This finding indicates that both lungs are expanding equally, which is a good sign.
Choice C rationale:
The assessment findings are mixed, with some findings suggesting improvement (oxygen saturation, ambulation without shortness of breath, symmetric chest expansion) and some findings suggesting that the infection is not fully resolved (diminished breath sounds, elevated PaCO2, rhonchi). This suggests that the treatment has been partially effective, but that the patient may need further treatment to fully resolve the pneumonia.
Choice D rationale:
It is important to evaluate the effectiveness of treatment over time, but the assessment findings in this case are clear enough to determine that the treatment has been partially effective.
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