Which patient does the LPN/LVN identify at high risk for hospital-acquired pneumonia?

A 35-year-old patient using the incentive spirometer following abdominal surgery

A 55-year-old patient who is eating in the chair following a rhinoplasty

A 40-year-old patient who refuses to cough and deep breath following a splenectomy

A24-year-old patient ambulating in the hall following an appendectomy

Answer and Explanation

The Correct Answer is C

C. This patient is at high risk for hospital-acquired pneumonia. After a splenectomy (removal of the spleen), patients may experience pain and discomfort, which can make them reluctant to perform necessary activities like coughing and deep breathing. These activities are crucial for preventing lung complications such as atelectasis and pneumonia.
A. This patient is actively using an incentive spirometer, which is a device that encourages deep breathing and helps keep the lungs clear. This practice significantly reduces the risk of developing pneumonia by preventing atelectasis (collapse of part of the lung) and promoting lung expansion.

B. This patient is out of bed and eating, which indicates they are relatively mobile and maintaining normal respiratory function. Rhinoplasty, a surgical procedure on the nose, generally does not impair lung function or significantly increase the risk of pneumonia. Being active and upright further reduces the risk of HAP.
D. This patient is actively ambulating, which is highly beneficial for lung function and overall recovery. Walking and moving around helps to prevent respiratory complications, including pneumonia, by promoting lung expansion and circulation.

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Free Nursing Study Resources

Correct Answer is D

Explanation

D. The priority focus in the acute management of hyperosmolar hyperglycemia is improving hydration status. Patients with HHS are severely dehydrated due to the osmotic diuresis caused by extremely high blood glucose levels. Rapid rehydration is critical to prevent shock, improve organ perfusion, and reduce blood glucose levels.
A. It's important to consider age-related changes in any patient but this is not the immediate priority in the acute management of hyperosmolar hyperglycemia. The primary concern is addressing the acute, life-threatening aspects of the condition.
B. Monitoring blood glucose levels is critical in managing hyperosmolar hyperglycemia. However, while it is essential to track the BG levels to guide insulin therapy and assess the response to treatment, it is not the immediate priority in terms of interventions needed to stabilize the patient initially.

C. Determining the underlying cause of hyperosmolar hyperglycemia, such as an infection or other illness, is important for comprehensive treatment. However, it is a secondary priority to stabilizing the patient’s current acute condition.

A. The diet stresses high-protein and low-carbohydrate intake, but people adapt to the restrictions. B. You will require special foods, but stores now stock a variety of choices for people with diabetes. C. Your diet will be a well-balanced, individualized meal plan that is healthy for your whole family. D. Sugars and fats need to be avoided, but the dietitian will help you find acceptable alternatives.

Correct Answer is C

Explanation

C. Medical nutrition therapy for diabetes involves creating a well-balanced, individualized meal plan that meets the patient's nutritional needs while helping to manage blood glucose levels. This approach can be healthy for the entire family and does not require separate meals or special foods. It promotes overall healthy eating habits that everyone can benefit from.
A. Low-carbohydrate diets may be considered for some patients but the emphasis of a diabetic diet is not necessarily on high-protein intake. Instead, the focus is on balanced meals that include appropriate amounts of carbohydrates, proteins, and fats.
B. People with diabetes do not require special foods; rather, they need to make healthier choices from the foods available. The emphasis is on a balanced diet that can include regular foods, with modifications to portion sizes and meal timing to manage blood glucose levels effectively.
D. It is not necessary to completely avoid sugars and fats; rather, the focus should be on moderating intake and choosing healthier options. For example, limiting added sugars and unhealthy fats (like trans fats and saturated fats) is important, but healthy fats (such as those from nuts, seeds, and avocados) can be part of a balanced diet.

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Which patient does the LPN/LVN identify at high risk for hospital-acquired pneumonia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is admitted to the hospital with hyperosmolar hyperglycemia. The patient has a BG value of 987 mg/dL. Which is the priority focus while providing care?

Correct Answer is D

Explanation

The nurse is assisting with nutrition teaching for a patient who voices concern over adjusting to a diabetic diet. Which response by the nurse about medical nutrition therapy is correct?

Correct Answer is C

Explanation

The nurse knows a patient with type 1 diabetes needs more education when the patient makes which of the following statements?

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

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

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What type of cells secrete insulin?

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?