The nurse is providing care for a patient admitted for a lower respiratory infection. On admission, the patient's vital signs were blood pressure (BP) 140/80 mm Hg. apical pulse (AP) 112 beats/minute, respirations (R) 32 breaths/minute, and pain level of 8 on a scale of 0 to 10. After assisting the patient to bed and applying the prescribed oxygen, which finding helps the nurse evaluate the effectiveness of nursing care?

P 100 beats/minute

R 20 breaths/minute

BP 130/78 mm Hg

Pain level of 6/10

Answer and Explanation

The Correct Answer is B

B. A decrease in the respiratory rate from 32 breaths/minute to 20 breaths/minute indicates improved respiratory status and effectiveness of nursing care. A lower respiratory rate suggests that the patient's breathing is becoming less labored, and oxygenation may be improving.
A. A lower heart rate may suggest a reduction in pain, improved oxygenation, or decreased stress on the cardiovascular system. However, other factors such as medications, rest, and hydration can also influence heart rate. Overall, a decrease in heart rate is a favorable finding.
C. A slight decrease in blood pressure from 140/80 mm Hg to 130/78 mm Hg may indicate a positive response to nursing care. However, blood pressure fluctuations can be influenced by various factors, including hydration status, medications, and underlying medical conditions.
D. Pain management is an essential aspect of nursing care, particularly for patients with lower respiratory infections who may experience discomfort due to coughing, chest congestion, and inflammation. However, pain levels can fluctuate over time and may require ongoing assessment and intervention.

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Correct Answer is A

Explanation

A. Holding the breath for at least 10 seconds after inhaling the medication allows the medication to settle in the lungs and increases its effectiveness. This ensures maximum delivery of the drug to the respiratory tract.
B. The recommended time to wait between inhalations is typically around 1 to 2 minutes, not 10 minutes. Waiting too long between puffs may reduce the effectiveness of the medication and is not necessary.
C. There is no specific recommendation that the inhaler must be held with the non-dominant hand. The inhaler should be held in the hand that feels most comfortable and provides the best control, which is usually the dominant hand for most people.
D. The correct technique involves tilting the head slightly back to open the airway, making it easier for the medication to reach the lungs. Tilting the head forward could restrict the airflow and reduce the effectiveness of the inhalation.

A. Tremor B. Lethargy C. Seizures D. Polydipsia E. Abdominal pain F. Sweating G. Polyuria H. Hunger

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"A"}}

Explanation

Hypoglycemia

Tremor is a common symptom of hypoglycemia, as low blood sugar levels can lead to shaky hands and trembling.

Seizures can occur in severe cases of hypoglycemia when the brain is deprived of glucose, leading to abnormal electrical activity and convulsions.

Sweating, particularly cold and clammy skin, is a common symptom of hypoglycemia as the body responds to low blood sugar levels.

Hunger or sudden feelings of extreme hunger are common symptoms of hypoglycemia as the body seeks additional fuel to raise blood sugar levels.

Hyperglycemia

Lethargy, or extreme fatigue and drowsiness, is more commonly associated with hyperglycemia, as elevated blood sugar levels can affect energy levels and lead to feelings of sluggishness.

Polydipsia is a classic symptom of hyperglycemia, as high blood sugar levels can cause dehydration and trigger the body's thirst response.

Abdominal pain is more commonly associated with hyperglycemia, particularly in conditions like diabetic ketoacidosis (DKA), where abdominal discomfort can be a sign of metabolic disturbances.

Polyuria is a classic symptom of hyperglycemia, as high blood sugar levels can lead to increased urine production as the kidneys work to remove excess glucose from the bloodstream.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with a client following an episode of status asthmaticus. The client has a prescription for two inhalations from an albuterol metered-dose inhaler. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

The nurse is providing discharge education about signs and symptoms of hypoglycemia and hyperglycemia. For each sign/symptom, indicate whether it is manifestation of hypoglycemia or hyperglycemia. Select one option in each row.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"A"}}

Explanation

The nurse is caring for a patient admitted with COPD, who is having difficulty breathing. Which actions can the nurse take to provide support? Select all that apply

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?

A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for GERD. Available is famotidine 40 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is reinforcing discharge teaching with a client who has a new diagnosis of gastroesophageal disease (GERD). Which of the following foods should the nurse include in the list of foods the client should avoid?

After reinforcing teaching on peptic ulcer disease, the nurse evaluates the patient as understanding the education if the patient states which of the following is a primary cause of peptic ulcer disease?

Which client would the nurse identify as high risk for developing aspiration pneumonia?

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?

The nurse is preparing to teach about the long-term complications for patients diagnosed with diabetes. Which finding is accurate?