A nurse is reviewing the medical record of a client who has been diagnosed with pneumonia.
Which of the following data should the nurse use to evaluate the effectiveness of the treatment plan?
The client's temperature is 37.2°C (99°F).
The client's white blood cell count is 12.5 x 10^9/L.
The client's oxygen saturation is 95% on room air.
The client's chest x-ray shows clear lung fields
The Correct Answer is D
The client's chest x-ray shows clear lung fields.
Rationale: A chest x-ray is a diagnostic test that can confirm the presence or absence of pneumonia by showing areas of consolidation or infiltration in the lung tissue. A clear chest x-ray indicates resolution of pneumonia and effectiveness of treatment.
Incorrect options:
A) The client's temperature is 37.2°C (99°F). - This is a normal finding, but it does not rule out pneumonia as some clients may have low-grade fever or no fever at all with pneumonia.
B) The client's white blood cell count is 12.5 x 10^9/L. - This is an elevated finding, as the normal range for white blood cell count is 4.5 to 11 x 10^9/L. An elevated white blood cell count indicates inflammation or infection and does not reflect the effectiveness of treatment.
C) The client's oxygen saturation is 95% on room air. - This is a normal finding, as the normal range for oxygen saturation is 95% to 100%. However, it does not indicate the severity or resolution of pneumonia, as some clients may have normal oxygen saturation despite having pneumonia.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
D) The client has an elevated troponin level in the blood.
Rationale: An elevated troponin level indicates myocardial damage and is a diagnostic marker for acute coronary syndrome (ACS), which includes unstable angina and myocardial infarction (MI). This is a life-threatening condition that requires immediate intervention.
A) The client has a history of hypertension and diabetes. - This is an important finding, as hypertension and diabetes are risk factors for cardiovascular disease, but it is not an urgent finding that requires immediate reporting.
B) The client rates the pain as 8 on a scale of 0 to 10. - This is a significant finding, as chest pain is a cardinal symptom of ACS, but it is not a definitive finding that confirms the diagnosis.
C) The client has crackles in the lower lobes of both lungs. - This is an abnormal finding, as crackles indicate fluid accumulation in the alveoli, which may be caused by heart failure, pneumonia, or pulmonary edema. However, it is not a specific finding for ACS and may be related to other conditions.
Correct Answer is A
Explanation
The Glasgow Coma Scale (GCS) is a tool that measures the level of consciousness based on three parameters: eye opening, verbal response, and motor response. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness.
Incorrect options:
B) Mini-Mental State Examination (MMSE) - This is a tool that measures cognitive function, such as orientation, memory, attention, and language. It is not used to assess level of consciousness.
C) Confusion Assessment Method (CAM) - This is a tool that screens for delirium, which is an acute and fluctuating disturbance of cognition and attention. It is not used to assess level of consciousness.
D) Morse Fall Scale (MFS) - This is a tool that assesses the risk of falling in hospitalized clients based on six factors: history of falling, secondary diagnosis, ambulatory aid, intravenous therapy, gait, and mental status. It is not used to assess level of consciousness.
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