Exhibits
A nurse is collecting data from an adolescent who has bacterial pneumonia. Which of the following findings is the priority for the nurse to report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Temperature
Skin condition
Oxygen saturation
Lung sounds
The Correct Answer is C
A. Temperature: A temperature of 38.6°C (101.5°F) is elevated, but fever is a common symptom of bacterial pneumonia. It is important to monitor, but it is not the most critical finding in this case.
B. Skin condition: Hives and flushing could be signs of an allergic reaction to medication, but this is not immediately life-threatening. The nurse should report it, but the priority in this case is the oxygen saturation, which reflects the patient's respiratory status.
C. Oxygen saturation: Oxygen saturation of 93% is below the typical threshold of 95-100% and indicates mild hypoxemia. In a patient with bacterial pneumonia, low oxygen saturation signify worsening respiratory function. This requires immediate attention and reporting.
D. Lung sounds: Coarse crackles in the right lower lobe are expected in pneumonia due to lung consolidation. While it is important to monitor lung sounds, the priority is addressing the oxygen saturation level, which is directly related to the patient's ability to breathe effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is "{\"xRanges\":[207.828125,247.828125],\"yRanges\":[145,185]}"
Explanation
Point A: Represents the third intercostal space at the right sternal border, which corresponds anatomically to the aortic valve area. This is a key auscultation site used during cardiac assessment to listen for murmurs and abnormalities related to the aortic valve. It is not used for palpation.
Point B: Fourth intercostal space at the left midclavicular line and is the correct location for palpating the point of maximal impulse (PMI) in infants and young children. In this age group, the PMI is typically found here due to the more horizontal position of the heart in the chest.
Point C: This location is at the 2nd or 3rd intercostal space, which is too high to assess the PMI in an infant. This area is used more for evaluating pulmonic valve sounds, not the apex of the heart.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Administer anticonvulsant: Since the adolescent is having symptoms that precede a seizure (blurred vision), administering an anticonvulsant as prescribed can help prevent or reduce seizure activity.
- Place the client lying on the side: Lying on the side ensures an open airway and reduces the risk of aspiration during a seizure. This position also allows secretions to drain safely.
Rationale for Incorrect Choices:
- Place a tongue blade in the client’s mouth: A tongue blade can cause injury to the teeth or mouth and increase choking risk. The proper approach is to place the client on their side and avoid putting objects in their mouth.
- Restrict movement in the extremities: Restricting movement could cause injury. The focus should be on safety by allowing the seizure to occur without interference while monitoring vital signs and activity.
Complete the following sentence by using the lists of options.
The nurse should recommend to