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 ["2.5"]
Explanation
Volume= Desired dose/ Available concentration per ml Available concentration per ml= 40mg/ 5ml
Available concentration= 8mg/ml Desired dose= 20mg
Volume= 20mg/ 8mg Volume= 2.5ml
Therefore, the nurse should administer 2.5ml of famotidine.
Correct Answer is D
Explanation
D. Sucralfate should be taken on an empty stomach, typically 1 hour before meals. This timing allows the medication to coat the ulcer site effectively and protect it from the acidic environment of the stomach, which increases after eating.
A. Taking sucralfate with an antacid can interfere with its action. Sucralfate works by forming a protective barrier on the ulcer site, and antacids can prevent sucralfate from binding properly to the ulcer. It's generally recommended to take sucralfate at least 30 minutes before or after antacids.
B. Sucralfate is not taken on an "as needed" basis for pain relief. It is prescribed as a regular, scheduled medication to provide continuous protection of the ulcer site. Pain relief from peptic ulcers comes as the ulcer heals, which sucralfate aids by protecting the mucosal lining.
C. Sucralfate does not need to be stored in the refrigerator. It should be stored at room temperature, away from moisture and heat, according to standard storage guidelines for most medications.
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