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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Correct Answer is D

Explanation

D. Duodenal ulcers are peptic ulcers that develop in the first part of the small intestine, known as the duodenum. They are the most common type of peptic ulcer. The classic symptom of a duodenal ulcer is intermittent upper abdominal pain that occurs about 2 to 3 hours after eating, particularly meals that contain acidic or spicy foods. The pain often wakes the patient from sleep and is relieved by eating or taking antacids.
A. Decubitus ulcers, also known as pressure ulcers or bedsores, are caused by prolonged pressure on the skin, typically over bony prominences. They occur due to impaired blood flow and tissue damage, often in individuals who are bedridden or immobile.
B. Gastric ulcers are peptic ulcers that develop in the lining of the stomach. While gastric ulcers can cause upper abdominal pain, they typically occur shortly after eating or during meals, rather than 3 hours after eating or at night.
C. Esophageal ulcers are peptic ulcers that develop in the lining of the esophagus. They are relatively rare compared to gastric and duodenal ulcers. Esophageal ulcers can cause symptoms such as chest pain, difficulty swallowing, and heartburn, but they are not typically associated with the timing of symptoms described by the client.

A. At bedtime B. In the morning C. After meals D. After start of antibiotics

Correct Answer is B

Explanation

B. Morning is considered the ideal time for collecting a sputum specimen. Overnight, mucus accumulates in the respiratory tract because the patient is less active and not clearing their throat or coughing as much. This means that the mucus is more concentrated and has had time to build up, providing a more substantial and representative sample of what is in the lungs.
A. Collecting a sputum specimen at bedtime is generally not ideal. By the end of the day, the patient’s respiratory tract might have cleared some of the accumulated mucus naturally through coughing or other activities.
C. Collecting a sputum specimen after meals is not recommended. Eating can introduce food particles and bacteria from the mouth into the sputum, contaminating the sample.
D. Starting antibiotics before collecting a sputum specimen can alter the bacterial flora present in the respiratory tract. This can lead to a false-negative result or an inaccurate representation of the pathogens causing the infection.

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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

Naxlex Comprehensive Predictor Exams

Your client has told you that they have been experiencing intermittent upper abdominal pain about 3 hours after eating and at times will even be awaken in the middle of the night by this pain. You suspect that your client may have which type of peptic ulcer?

Correct Answer is D

Explanation

Which time would be ideal for the LPN/LVN to collect a sputum specimen?

Correct Answer is B

Explanation

A patient with newly diagnosed diabetes asks the nurse what to take for low blood sugar. Which of the following would be most appropriate for the nurse to suggest?

The LPN/LVN is providing teaching for a patient with type 2 diabetes. Which statement indicates an understanding by the patient?

A nurse is reinforcing discharge teaching with a client following an episode of status asthmaticus. The client has a prescription for two inhalations from an albuterol metered-dose inhaler. Which of the following statements by the client indicates an understanding of the teaching?

The nurse is caring for a patient with pneumonia. Which lab abnormality is most concerning?

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

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?

The nurse enters a room of a patient who is acutely short of breath. Which action should the nurse take first?