Patient Data

Exhibits

The nurse is planning care for the client

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

The nurse should:

Raise the head of the bed to aid in breathing.
Change to a face mask for oxygen delivery to address hypoxia.

The nurse should monitor:

Lung sounds to assess the progression of pneumonia.
Oxygen saturation to ensure the patient is receiving adequate oxygen.

Choice A reason: Increasing IV fluids is important in the care of pneumonia patients to prevent dehydration, especially if the patient has fever and increased respiratory rate which can lead to fluid loss. However, in this case, the patient’s blood pressure is stable, and there is no indication of dehydration, so this would not be the immediate action.

Choice B reason: Raising the head of the bed can help improve the patient’s breathing by reducing pressure on the chest and aiding in lung expansion. This is a standard care practice for patients with respiratory difficulties and is particularly beneficial for those with pneumonia to facilitate easier breathing.

Choice C reason: Bronchodilator nebulization can help open airways and improve breathing in patients with respiratory conditions. While it may be used in the treatment of pneumonia, it is not the primary intervention for hypoxia.

Choice D reason: Changing to a face mask for oxygen delivery is a critical intervention for a patient experiencing hypoxia. The patient’s oxygen saturation is 88% on 2 L/minute via nasal cannula, which is below the normal range of 95-100%3. A face mask can deliver higher concentrations of oxygen, which is necessary to address the patient’s hypoxia.

Choice E reason: Calling a rapid response team is necessary if the patient’s condition is deteriorating rapidly and requires immediate medical intervention. In this scenario, while the patient is hypoxic, there is no indication of acute decompensation that would necessitate a rapid response team at this moment.

Choice F reason: Pneumothorax, or collapsed lung, would present with sudden chest pain and shortness of breath. The patient’s history and symptoms are more consistent with pneumonia rather than pneumothorax.

Choice G reason: Hypoventilation refers to decreased breathing efficiency, leading to increased levels of carbon dioxide in the blood. While the patient does have difficulty breathing, the primary issue seems to be the impaired oxygen exchange due to pneumonia, rather than hypoventilation.

Choice H reason: Atelectasis is the collapse of part of the lung, which can occur after surgery or with bedridden patients. This patient’s symptoms are more indicative of an infectious process rather than atelectasis.

Choice I reason: Hypoxia is a condition where the body or a region of the body is deprived of adequate oxygen supply. Given the patient’s low oxygen saturation level and bilateral lower lobe pneumonia, hypoxia is the most likely condition the patient is experiencing.

Choice J reason: Monitoring lung sounds is essential for assessing the effectiveness of treatment and progression of pneumonia. Diminished lung sounds can indicate poor air movement due to the infection.

Choice K reason: Changes in the level of consciousness can indicate worsening hypoxia and should be monitored closely. A decrease in consciousness can be a sign of inadequate brain oxygenation.

Choice L reason: Oxygen saturation is a direct measure of the patient’s respiratory status and should be monitored to assess the effectiveness of oxygen therapy and overall progression.

Choice M reason: While heart rhythm should be monitored in all patients, it is not the most specific parameter for assessing the progression of pneumonia or hypoxia.

Choice N reason: Temperature should be monitored to assess for fever, which can indicate infection or inflammation. However, it is not as directly related to respiratory function as oxygen saturation and lung sounds are in the context of pneumonia.

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Correct Answer is ["A","E","F"]

Explanation

Choice A reason: Monitoring for fever is essential after cardiac procedures like the one described. Fever can be a sign of infection, which is a risk following any invasive procedure. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C) for a typical child, but it can be slightly lower in the morning and higher in the late afternoon and evening.
Choice B reason: There is no need to restrict the child to clear liquids for several days unless specifically instructed by the physician for a particular reason. After cardiac catheterization, patients are usually encouraged to resume their normal diet as tolerated to promote recovery unless there are other concerns that warrant dietary restrictions1.
Choice C reason: Avoiding baths or showers is generally recommended immediately after cardiac catheterization to prevent infection at the catheter insertion site. However, this restriction is usually only for a few days, not indefinitely. The site needs to be kept dry and clean until it has sufficiently healed.
Choice D reason: Keeping a pressure dressing on the site for one week is not typically necessary. The dressing is usually checked and changed by healthcare professionals, and the site is monitored for healing. The dressing may be removed after a certain period, often before one week, as long as there are no signs of bleeding or infection.
Choice E reason: Alerting the physician if the site bleeds or swells is crucial. Swelling or bleeding can indicate complications such as infection or hematoma formation. Parents should be instructed to look for any signs of abnormal discharge, redness, or increased pain, which could signify an infection.
Choice F reason: The child may take ibuprofen for pain, but it should be under the guidance of a physician. Ibuprofen is an NSAID that can help with pain and inflammation. However, it’s important to use the correct dosage and to ensure it doesn’t interfere with any other medications the child may be taking.

A. Obtain a urine specimen for culture and sensitivity. B. Instruct in effective techniques to cleanse the glans penis. C. Palpate the client's suprapubic area for distention. D. Advise the client to maintain a voiding diary for one week.

Correct Answer is C

Explanation

Choice A reason: While obtaining a urine specimen is important for diagnosing infection, it does not address the immediate discomfort and potential urinary retention the client may be experiencing.

Choice B reason: Cleansing the glans penis is part of good hygiene but does not address the client's symptoms of a full bladder and weak urine flow.

Choice C reason: Palpating for suprapubic distention can provide immediate information about bladder fullness and potential urinary retention, which may require prompt intervention.

Choice D reason: Maintaining a voiding diary is useful for tracking symptoms over time but does not provide an immediate assessment or intervention for the client's current symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse educates the parents on post discharge care for the child. What should the nurse include in post discharge care education? Select all that apply.

Correct Answer is ["A","E","F"]

Explanation

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is C

Explanation

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