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 []
Explanation
Potential Condition: Increased intracranial pressure
Actions to Take:
Measure head circumference: This action is important to monitor for signs of increasing intracranial pressure, as a bulging and tense fontanel suggests possible hydrocephalus or other intracranial pathology.
Plan to assist with administration of antibiotics: Antibiotics may be necessary if there is suspected meningitis or another infectious cause contributing to increased intracranial pressure.
Parameters to Monitor:
Behavioral changes: Monitor for irritability, difficulty to console, and other behavioral changes which can indicate neurological distress.
Pupillary response: Assess for changes in pupillary size and reactivity, as altered pupillary responses can indicate neurological involvement and increased intracranial pressure.
Correct Answer is B
Explanation
A. The sensor should be applied to a site where it can provide accurate readings, but not specifically to the fingernail.
B. Repositioning the probe every 2 hours helps prevent skin irritation and ensures accurate readings.
C. Warming the skin prior to probe placement is not necessary and is not standard practice unless the client has circulatory compromise.
D. Taping the wire to the palm of the hand is not necessary and may cause discomfort or interfere with accurate readings.
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