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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. An elevated white blood cell (WBC) count, specifically an elevation in the neutrophil count (neutrophilia), is commonly seen in pneumonia. It indicates an inflammatory response to the infection and is a typical finding in bacterial pneumonia.
A. A decreased serum creatinine level is not typically associated with pneumonia and may not be directly related to the condition. In fact, it may suggest impaired kidney function or dehydration, but it is not a concerning lab abnormality specifically related to pneumonia.
C. Protein in the urine (proteinuria) may be present in various conditions, including kidney disease, urinary tract infections, and certain systemic illnesses. While it can sometimes be seen in severe cases of pneumonia, it is not a specific or common finding associated with the condition.
D. Decreased serum potassium levels are not typically associated with pneumonia itself. However, certain factors related to pneumonia treatment or complications, such as the use of diuretics or vomiting, could lead to hypokalemia. While hypokalemia can have serious consequences, it is not directly related to the severity of pneumonia.
Correct Answer is B
Explanation
B. Morning is considered the ideal time for collecting a sputum specimen. Overnight, mucus accumulates in the respiratory tract because the patient is less active and not clearing their throat or coughing as much. This means that the mucus is more concentrated and has had time to build up, providing a more substantial and representative sample of what is in the lungs.
A. Collecting a sputum specimen at bedtime is generally not ideal. By the end of the day, the patient’s respiratory tract might have cleared some of the accumulated mucus naturally through coughing or other activities.
C. Collecting a sputum specimen after meals is not recommended. Eating can introduce food particles and bacteria from the mouth into the sputum, contaminating the sample.
D. Starting antibiotics before collecting a sputum specimen can alter the bacterial flora present in the respiratory tract. This can lead to a false-negative result or an inaccurate representation of the pathogens causing the infection.
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.
