Which vital signs are most important for a patient who is experiencing shortness of breath?
Temperature, pulse, blood pressure
Pulse, respirations, oxygen saturation
Temperature, pulse, respirations
Respirations, blood pressure, pain
The Correct Answer is B
Choice A reason: This is an incorrect choice because temperature, pulse, and blood pressure are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and pulse and blood pressure can be affected by other factors, such as anxiety or medication.
Choice B reason: This is the correct choice because pulse, respirations, and oxygen saturation are the most important vital signs for a patient who is experiencing shortness of breath. Pulse reflects the heart rate and rhythm, which can be altered by respiratory distress. Respirations reflect the rate and depth of breathing, which can indicate the severity of the condition. Oxygen saturation reflects the percentage of hemoglobin that is bound with oxygen, which can indicate the adequacy of oxygenation.
Choice C reason: This is an incorrect choice because temperature, pulse, and respirations are not the most important vital signs for a patient who is experiencing shortness of breath. Temperature is not directly related to respiratory function, and respirations alone do not provide enough information about the oxygenation status of the patient.
Choice D reason: This is an incorrect choice because respirations, blood pressure, and pain are not the most important vital signs for a patient who is experiencing shortness of breath. Blood pressure can be affected by other factors, such as anxiety or medication, and pain is a subjective symptom that can vary from person to person. Oxygen saturation is a more objective and reliable indicator of oxygenation than pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Making sure that the earpieces fit loosely in the nurse’s ear canals will not help the nurse hear the heartbeat more clearly. Loose earpieces can let in ambient noise and reduce the sound quality.
Choice B reason: This is incorrect. Utilizing a stethoscope with the longest possible tubing will not help the nurse hear the heartbeat more clearly. Long tubing can reduce the sound transmission and create interference.
Choice C reason: This is correct. Placing the diaphragm firmly against the patient’s skin will help the nurse hear the heartbeat more clearly. The diaphragm is the flat circular part of the chest piece that is used to listen to low-pitched sounds, such as the heart. Firm pressure creates a good seal and blocks out external noise.
Choice D reason: This is incorrect. Positioning the bell very lightly over the patient’s sternum will not help the nurse hear the heartbeat more clearly. The bell is the small cup-shaped part of the chest piece that is used to listen to high-pitched sounds, such as the lungs. Light pressure is needed to avoid activating the diaphragm, but the sternum is not the best location to listen to the apical pulse.
Correct Answer is C
Explanation
Choice A reason: This is an incorrect choice because powerlessness related to inability to keep from eating during sleep is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Powerlessness is a psychosocial problem that affects the patient's sense of control and self-efficacy. However, it is not the most urgent or life-threatening problem for the patient, as it does not pose an immediate risk of harm or injury.
Choice B reason: This is an incorrect choice because wandering related to cognitive impairment from sleeping aid is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Wandering is a behavioral problem that involves moving about aimlessly or without purpose. However, it is not the most urgent or life-threatening problem for the patient, as it does not necessarily imply a risk of harm or injury.
Choice C reason: This is the correct choice because risk for falls related to ambulating to kitchen while asleep is the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Risk for falls is a safety problem that involves an increased likelihood of falling due to factors such as impaired balance, coordination, or judgment. This is the most urgent and life-threatening problem for the patient, as it can result in serious injuries or complications.
Choice D reason: This is an incorrect choice because risk for imbalanced nutrition: more than body requirements related to sleep eating is not the highest priority nursing diagnosis for a patient who developed sleep-related eating disorder when taking Zolpidem. Risk for imbalanced nutrition: more than body requirements is a physiological problem that involves an intake of nutrients that exceeds metabolic needs. However, it is not the most urgent or life-threatening problem for the patient, as it does not cause an immediate risk of harm or injury.
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