A patient is admitted to a respiratory unit with a diagnosis of bacterial pneumonia. Findings include a fever and a weak, congested-sounding cough with moist crackles throughout the lung fields. How should the nurse prioritize care?
Difficulty with breathing
Inability to clear the airway
Confusion from fever
Inadequate oxygen level
The Correct Answer is B
B. The inability to clear the airway is a critical issue. This patient has a weak, congested-sounding cough and moist crackles, indicating that secretions are present and not being effectively cleared. This can lead to airway obstruction, decreased oxygenation, and further respiratory complications. Clearing the airway is a top priority to ensure the patient can breathe properly and prevent further deterioration.
A. Difficulty breathing (dyspnea) is a serious concern as it can indicate respiratory distress or failure. However, it is often a symptom rather than a primary issue, and its underlying causes (such as an inability to clear the airway or inadequate oxygen levels) must be addressed first.
C. Confusion can result from high fever, infection, or hypoxia. While it is important to address the fever and its underlying cause, confusion itself is usually a secondary issue. Addressing the primary respiratory issues will often improve the patient's mental status as well.
D. Hypoxia can result from severe pneumonia, and resolving it involves ensuring the patient has a clear airway and adequate ventilation. Measuring and correcting oxygen levels (e.g., with supplemental oxygen) is crucial, but the underlying cause (such as airway obstruction) must also be managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Duodenal ulcers are peptic ulcers that develop in the first part of the small intestine, known as the duodenum. They are the most common type of peptic ulcer. The classic symptom of a duodenal ulcer is intermittent upper abdominal pain that occurs about 2 to 3 hours after eating, particularly meals that contain acidic or spicy foods. The pain often wakes the patient from sleep and is relieved by eating or taking antacids.
A. Decubitus ulcers, also known as pressure ulcers or bedsores, are caused by prolonged pressure on the skin, typically over bony prominences. They occur due to impaired blood flow and tissue damage, often in individuals who are bedridden or immobile.
B. Gastric ulcers are peptic ulcers that develop in the lining of the stomach. While gastric ulcers can cause upper abdominal pain, they typically occur shortly after eating or during meals, rather than 3 hours after eating or at night.
C. Esophageal ulcers are peptic ulcers that develop in the lining of the esophagus. They are relatively rare compared to gastric and duodenal ulcers. Esophageal ulcers can cause symptoms such as chest pain, difficulty swallowing, and heartburn, but they are not typically associated with the timing of symptoms described by the client.
Correct Answer is B
Explanation
B. Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen, are known to increase the risk of peptic ulcer formation by disrupting the protective mucosal barrier of the stomach and duodenum.
Long-term or frequent use of NSAIDs can lead to mucosal damage and ulceration.
A. Consuming spicy foods frequently may irritate the lining of the stomach and increase the risk of developing peptic ulcers. However, the number of consumed meals is not specific to the risl of peptic ulcer formation.
C. Green tea consumption is generally not considered a significant risk factor for peptic ulcers. In fact, some studies suggest that compounds found in green tea may have protective effects against the development of peptic ulcers and may help reduce the risk of H. pylori infection, a common cause of ulcers.
D. Bulimia, an eating disorder characterized by binge eating followed by purging behaviors such as vomiting, is a risk factor for peptic ulcers. The repeated exposure of stomach acid to the esophagus and stomach lining due to vomiting can lead to inflammation and ulceration of the gastrointestinal tract.
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