A nurse is assisting with the care of a 15-year-old adolescent who has Streptococcus pneumonia.
The nurse is collecting data on the adolescent 24 hr later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the admitting diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
WBC count 17,000/mm3
Steatorrhea
Oxygen saturation 95% on 1 L oxygen via nasal cannula
Barrel chest
Hemoptysis 300 ML
Respiratory rate 32/min
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"}}
WBC count 17,000/mm3: Indication of Potential Improvement. The initial WBC count was 22,000/mm3, and 24 hours later, it has decreased to 17,000/mm3, indicating improvement.
Steatorrhea: Unrelated to Diagnosis. This symptom is typically associated with cystic fibrosis rather than pneumonia.
Oxygen saturation 95% on 1 L oxygen via nasal cannula: Indication of Potential Improvement. The decrease in oxygen requirement from 2 L to 1 L suggests the adolescent's respiratory status may be improving.
Barrel chest: Unrelated to Diagnosis. This physical finding is more indicative of chronic conditions such as cystic fibrosis rather than an acute pneumonia presentation.
Hemoptysis 300 mL: Indication of Potential Worsening Condition. The presence of significant hemoptysis indicates a worsening condition, possibly due to progression or complications of pneumonia.
Respiratory rate 32/min: Indication of Potential Improvement. The decrease in respiratory rate from 36/min to 32/min suggests a possible improvement in respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Checking the color and temperature of the toes helps assess for adequate circulation and potential complications like compartment syndrome.
B. Applying cushioning to the cast edges is important for comfort but is not the immediate priority.
C. Using a fan can help the cast dry faster but is not the priority action.
D. Repositioning the toddler is important to prevent pressure sores, but ensuring proper circulation takes precedence.
Correct Answer is []
Explanation
Condition:
Pyelonephritis: The presence of fever, frequent and painful urination, and costovertebral angle tenderness, along with the urinalysis findings (cloudy urine, leukocyte esterase, nitrites, WBCs) and elevated WBC count suggest an upper urinary tract infection, likely pyelonephritis.
Actions to Take:
Request prescription for antibiotics: Pyelonephritis is a bacterial infection that requires antibiotic treatment to prevent complications and resolve the infection.
Encourage increased fluid intake: This helps to flush bacteria from the urinary tract, reducing the concentration of bacteria in the urine and helping to relieve symptoms.
Parameters to Monitor:
Child’s report of urgency: This can help assess if the infection is affecting the lower urinary tract as well and track the effectiveness of treatment.
Urine odor: Foul-smelling urine can indicate ongoing infection or bacterial presence and can be an indicator of the effectiveness of the treatment.
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