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 C
Explanation
C. Monitoring blood sugar levels regularly, as recommended by the doctor, is crucial for managing type 2 diabetes effectively. It helps patients track their glucose levels, identify patterns, and make informed decisions about medication, diet, and lifestyle choices to maintain optimal blood sugar control.
A. Drinking orange juice to treat high blood sugar is not recommended because it can cause a rapid increase in blood sugar levels due to its high sugar content. Instead, patients should focus on consuming foods or beverages with lower glycemic index values and more stable glucose responses.
B. Regular physical activity is an essential component of diabetes management as it helps improve insulin sensitivity, lower blood sugar levels, control weight, and reduce the risk of complications. Patients with diabetes are encouraged to engage in regular exercise as part of their overall treatment plan.
D. Eating a diet high in carbohydrates can lead to spikes in blood sugar levels, which can be detrimental for individuals with type 2 diabetes. Instead, patients are encouraged to follow a balanced diet that includes a variety of nutrient-rich foods, with a focus on whole grains, lean proteins, healthy fats, fruits, and vegetables, while moderating carbohydrate intake.
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