A 33-year-old patient has pneumonia. When the nurse assesses this patient, which of the following data will receive the highest priority?

presence of hiccups, amount of sweating BP

capillary refill, amount of sputum, trembling

size of pupil, presence of sneezing, location of pain

restlessness, chest wall movement, color of nails

Answer and Explanation

The Correct Answer is D

D. Restlessness can be an early sign of hypoxia. Chest wall movement provides information about the effort and effectiveness of breathing, and the color of the nails can indicate cyanosis, which is a sign of poor oxygenation. These data points are directly related to assessing respiratory status and the severity of pneumonia.

A. Hiccups, sweating, and blood pressure can provide useful information about the patient's condition, they do not directly indicate the severity of respiratory distress or oxygenation status. Hiccups can be a sign of diaphragmatic irritation, sweating can indicate fever or infection, and blood pressure is a general vital sign but not specific to respiratory function.
B. Capillary refill can provide information about peripheral perfusion, and the amount of sputum can be relevant to respiratory status, particularly in an infection like pneumonia. Trembling might indicate fever or anxiety but is less directly related to respiratory status compared to other signs.
C. Pupil size and sneezing are not directly related to respiratory function in pneumonia. Pain location could be relevant if it indicates pleuritic pain, but this set of data does not provide the most critical information for assessing respiratory function and oxygenation in a patient with pneumonia.

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Free Nursing Study Resources

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.

A. Cardiovascular exercise B. Beta-blocking medications C. Exposure to secondhand smoke D. Carpet and drapes in the bedroom E. Pets and foods that cause symptoms

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

Explanation

B. Beta-blocking medications, such as propranolol and metoprolol, can worsen asthma symptoms in some individuals by constricting the airways. Patients with asthma should avoid or use caution with beta-blockers, especially non-selective ones, as they can trigger or exacerbate asthma attacks.
C. Exposure to secondhand smoke is a well-established trigger for asthma symptoms and can exacerbate respiratory inflammation and airway hyperresponsiveness. Patients with asthma should avoid exposure to secondhand smoke whenever possible to reduce the risk of asthma exacerbations.
D. Carpeting and drapes can harbor dust mites, pet dander, and other allergens that can trigger asthma symptoms in susceptible individuals. Patients with asthma may benefit from removing carpeting and minimizing soft furnishings in the bedroom to reduce exposure to allergens and improve air quality.
E. Pets, particularly those with fur or feathers, can be potent allergens for individuals with asthma. Patients with asthma should consider removing pets from the home or at least keeping them out of the bedroom to minimize exposure to pet dander.
A. Cardiovascular exercise can trigger asthma symptoms in some individuals but it is not typically recommended to eliminate exercise altogether. Instead, patients with asthma should be encouraged to engage in physical activities that are well-tolerated and to use appropriate preventive measures, such as pre-exercise bronchodilator therapy and warm-up exercises, to minimize symptoms.

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A 33-year-old patient has pneumonia. When the nurse assesses this patient, which of the following data will receive the highest priority?

Nursing Test Bank

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