A nurse is caring for a client in an acute care setting.
The client is at risk for ________ as evidences by __________.
Complete the following sentence by using the list of options. Pick 2 choices.
Hypostatic pneumonia.
Anemia.
Fluid volume overload.
Immobility.
Calorie deficiency.
Correct Answer : A,D
Hypostatic Pneumonia Hypostatic pneumonia is a type of pneumonia that occurs when fluid or secretions settle in the lower lobes of the lungs, typically due to a lack of movement or staying in one position for too long. In this case, the client has paraplegia, which is a form of significant immobility. This condition prevents the client from effectively clearing their airway and results in decreased lung expansion.
Analysis of Evidence The clinical findings on Day 2 clearly indicate a progression toward an infectious respiratory process caused by this immobility:
-
Respiratory Status: The oxygen saturation has dropped from 95% to 89%, and the respiratory rate has increased from 20/min to 24/min (tachypnea).
-
Symptoms: The client has transitioned from a simple cough to a productive cough and is now experiencing confusion, which is a common sign of hypoxia in clinical settings.
-
Infection Markers: The client's temperature has risen to 38.4°C (101.1°F), and the WBC count is elevated at 12,500/mm³, indicating a systemic inflammatory response or infection.
-
Tachycardia: The heart rate has increased to 105/min, which is a compensatory mechanism for decreased oxygenation and the presence of a fever.
While the client's Hgb is slightly low (11.0 g/dL), it does not explain the acute onset of fever, confusion, and productive cough. Furthermore, there are no signs of fluid volume overload (such as edema or high BP) or calorie deficiency that would trigger these specific respiratory and febrile symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: b. Determine goals of the day.
Choice A: Schedule daily activities.
Rationale: Scheduling daily activities is crucial for time management but should follow establishing goals. The nurse must first determine the priorities and objectives for the day before organizing the tasks.
Choice B: Determine goals of the day.
Rationale: Identifying the goals of the day is the first step in effective time management for a nurse. This enables the nurse to prioritize patient care and other responsibilities, ensuring that essential tasks are accomplished and patient needs are met. Goals can include completing assessments, administering medications, and attending to patient concerns.
Choice C: Delegate tasks to the AP.
Rationale: Delegating tasks is vital in managing time and resources, but it should occur after the goals and priorities are determined. The nurse must first know which tasks need to be completed before assigning responsibilities to the LPN and AP.
Choice D: Develop an hourly time frame for tasks.
Rationale: Creating a timeline for tasks is essential for time management but should be done after setting goals and prioritizing tasks. This will enable the nurse to allocate an appropriate amount of time for each task and help ensure that all necessary tasks are completed within the shift.
In conclusion, by first determining the goals of the day, the nurse can effectively manage time and ensure that all essential tasks are completed. Prioritizing patient care and other responsibilities will enable the nurse to collaborate effectively with the LPN and AP in delegating tasks and scheduling activities.
Correct Answer is A
Explanation
Choice A rationale:
Potato pancakes made from potatoes do not contain gluten, making them suitable for someone with celiac disease. Gluten is a protein found in wheat, barley, and rye, so individuals with celiac disease must avoid foods containing these grains.
Choice B rationale:
Wheat crackers contain gluten and are not appropriate for someone with celiac disease. Avoiding gluten is crucial for individuals with this condition to prevent damage to the small intestine.
Choice C rationale:
White flour tortillas are typically made from wheat flour and contain gluten. Individuals with celiac disease should avoid products made from wheat flour to prevent adverse reactions.
Choice D rationale:
Canned barley soup contains barley, which is a gluten-containing grain. Individuals with celiac disease should avoid barley-based products as they contain gluten.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.