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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A, B, C, D, E
Explanation
A. Shake the canister 3 to 5 seconds vigorously.
Before each use, it's important to shake the MDI to ensure proper mixing of the medication.
B. Place her lips firmly around the mouthpiece.
Creating a tight seal around the mouthpiece ensures that the medication is delivered directly into the airways.
C. Inhale slowly over 3 to 5 seconds while pushing down on the canister.
While pressing down on the canister, the client should inhale slowly to allow the medication to reach the lungs.
D. Hold her breath for 10 seconds.
After inhaling the medication, holding the breath for 10 seconds allows for better absorption of the medication into the lungs.
E. Exhale slowly through pursed lips.
After holding the breath, exhaling slowly through pursed lips helps to fully exhale and ensures that the medication remains in the airways.
Correct Answer is B
Explanation
B. Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen, are known to increase the risk of peptic ulcer formation by disrupting the protective mucosal barrier of the stomach and duodenum.
Long-term or frequent use of NSAIDs can lead to mucosal damage and ulceration.
A. Consuming spicy foods frequently may irritate the lining of the stomach and increase the risk of developing peptic ulcers. However, the number of consumed meals is not specific to the risl of peptic ulcer formation.
C. Green tea consumption is generally not considered a significant risk factor for peptic ulcers. In fact, some studies suggest that compounds found in green tea may have protective effects against the development of peptic ulcers and may help reduce the risk of H. pylori infection, a common cause of ulcers.
D. Bulimia, an eating disorder characterized by binge eating followed by purging behaviors such as vomiting, is a risk factor for peptic ulcers. The repeated exposure of stomach acid to the esophagus and stomach lining due to vomiting can lead to inflammation and ulceration of the gastrointestinal tract.
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