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 A
Explanation
A. Determine if the toddler has an allergy to iodine prior to the procedure: Cardiac catheterization typically involves the use of iodine-based contrast dye. It is crucial to determine if the toddler has an allergy to prevent any adverse reactions, during the procedure.
B. Check the toddler's vital signs once each hour following the procedure: After a cardiac catheterization, vital signs should be monitored more frequently than once per hour. Typically every 15-30 minutes during the first few hours following the procedure to detect any complications.
C. Give the toddler clear liquids prior to the procedure: Clear liquids are restricted before a procedure like cardiac catheterization, especially if sedation or anesthesia is involved. The child may be required to fast for several hours before the procedure to reduce the risk of aspiration.
D. Administer meperidine for pain immediately following the procedure: Meperidine is not recommended for pain management in children due to its potential for side effects, including seizures. Safer alternatives, like acetaminophen or morphine, are preferred
Correct Answer is C
Explanation
A. Pinto beans: Pinto beans are a good source of protein, but they are not considered a complete protein. They lack some of the essential amino acids, although they can be paired with other foods (like rice) to form a complete protein.
B. Peanut butter: Peanut butter is a good source of protein, but like pinto beans, it is not a complete protein. It lacks some essential amino acids, and while it can be part of a balanced diet, it does not provide all the necessary amino acids on its own.
C. Eggs: Eggs are an excellent source of complete protein because they contain all nine essential amino acids that the body cannot produce on its own. They are considered one of the best sources of high-quality, complete protein.
D. Broccoli: While broccoli contains some protein, it is not a complete protein. It provides some essential amino acids, but not all nine, so it does not qualify as a complete protein source on its own.
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