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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Correct Answer is B

Explanation

B. The inability to clear the airway is a critical issue. This patient has a weak, congested-sounding cough and moist crackles, indicating that secretions are present and not being effectively cleared. This can lead to airway obstruction, decreased oxygenation, and further respiratory complications. Clearing the airway is a top priority to ensure the patient can breathe properly and prevent further deterioration.
A. Difficulty breathing (dyspnea) is a serious concern as it can indicate respiratory distress or failure. However, it is often a symptom rather than a primary issue, and its underlying causes (such as an inability to clear the airway or inadequate oxygen levels) must be addressed first.
C. Confusion can result from high fever, infection, or hypoxia. While it is important to address the fever and its underlying cause, confusion itself is usually a secondary issue. Addressing the primary respiratory issues will often improve the patient's mental status as well.
D. Hypoxia can result from severe pneumonia, and resolving it involves ensuring the patient has a clear airway and adequate ventilation. Measuring and correcting oxygen levels (e.g., with supplemental oxygen) is crucial, but the underlying cause (such as airway obstruction) must also be managed.

A. "I will drink less fluid." B. "I will try not to gain weight" C. "I will sleep with the head of my bed elevated." D. “I will consume less caffeine and spicy foods." E. “I will lie down for one half hour after meals."

Correct Answer is ["B","C","D"]

Explanation

B. Maintaining a healthy weight is important for managing a hiatal hernia. Excess body weight can increase abdominal pressure and exacerbate symptoms. Weight loss, if necessary, can help reduce the frequency and severity of symptoms.
C. Elevating the head of the bed helps prevent the reflux of stomach contents into the esophagus while sleeping. Gravity helps keep the stomach contents down, reducing the risk of acid reflux and associated symptoms.
D. Caffeine and spicy foods can irritate the stomach lining and exacerbate symptoms of hiatal hernia, such as heartburn and acid reflux. Reducing the intake of these foods can help manage symptoms.
A. This is not typically a recommendation for managing a hiatal hernia. Drinking fluids is important for overall health and digestion. However, it is advisable to avoid drinking large amounts of fluids quickly, especially with meals, as this can increase intra-abdominal pressure and worsen symptoms.
E. Lying down after meals can increase the risk of reflux and worsen symptoms of a hiatal hernia. It is generally recommended to remain upright for at least a couple of hours after eating to prevent reflux.

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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 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?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about dietary recommendations for a client who has a hiatal hernia. Which of the following client statements indicate understanding of the teaching? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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