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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Patients who have had a stroke are at high risk for aspiration pneumonia due to potential impairment of their swallowing mechanisms and decreased gag reflex, which can occur if the stroke affects the parts of the brain that control these functions. Dysphagia is a common complication of strokes and significantly increases the risk of aspiration.
A. Migraines can cause significant discomfort and sometimes nausea and vomiting, they do not typically impair swallowing or protective airway reflexes. Thus, this patient is not at high risk for aspiration pneumonia.
B. Leukemia itself does not directly increase the risk of aspiration pneumonia. However, if the patient has complications such as severe weakness, altered mental status, or treatment side effects (like mucositis or infections), their risk could be increased, but it is not the primary concern in most leukemia cases.
C. Asthma affects the airways and causes difficulty breathing but does not typically impair swallowing or increase the risk of aspiration. While severe asthma attacks can cause coughing and choking, the primary issue is airway inflammation, not the risk of inhaling food or liquid.
Correct Answer is ["2.5"]
Explanation
Volume= Desired dose/ Available concentration per ml Available concentration per ml= 40mg/ 5ml
Available concentration= 8mg/ml Desired dose= 20mg
Volume= 20mg/ 8mg Volume= 2.5ml
Therefore, the nurse should administer 2.5ml of famotidine.
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