A 51-year-old male client with pneumonia has undergone several days of antibiotic and respiratory treatment. Given the following assessment findings, mark whether they indicate that the treatment was effective or ineffective:
PaCO2 55 mm Hg on a blood gas
Rhonchi in the right lung
Oxygen saturation greater than 94%
Client ambulates without shortness of breath
Correct Answer : C,D
Choice A rationale:
PaCO2 55 mm Hg on a blood gas indicates ineffective treatment. Normal PaCO2 levels range from 35-45 mm Hg.
Elevated PaCO2 (hypercapnia) suggests that the lungs are not effectively removing carbon dioxide from the body. This can be due to various factors, including:
Incomplete resolution of pneumonia Airway obstruction
Impaired respiratory muscle function
Choice B rationale:
Rhonchi in the right lung indicates ineffective treatment.
Rhonchi are coarse, rattling sounds heard in the lungs during auscultation.
They are often associated with mucus accumulation in the airways, which can occur in pneumonia.
The presence of rhonchi suggests that inflammation and mucus production persist, despite antibiotic and respiratory therapy.
Choice C rationale:
Oxygen saturation greater than 94% indicates effective treatment. Normal oxygen saturation levels are typically 95% or higher.
A saturation of 94% or above suggests that the lungs are able to effectively oxygenate the blood. This is a positive sign that the pneumonia is responding to treatment.
Choice D rationale:
Client ambulates without shortness of breath indicates effective treatment. Shortness of breath (dyspnea) is a common symptom of pneumonia.
It occurs when the lungs are unable to provide enough oxygen to the body, leading to a feeling of breathlessness.
The ability to ambulate without shortness of breath suggests that the pneumonia has improved and that the lungs are functioning more effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While teaching the client about infection prevention measures is important, it is not the most crucial action in this situation. The client is already exhibiting symptoms and has potentially been spreading the virus.
Focusing on isolation at this point is a more effective way to prevent further transmission.
Additionally, the client may be too ill to fully comprehend or adhere to instructions regarding masks, handwashing, and social distancing.
Choice B rationale:
Isolation is the most essential action to prevent the spread of COVID-19 to others. This is because:
COVID-19 is highly contagious and can spread through respiratory droplets produced when an infected person coughs, sneezes, or talks.
Isolation physically separates the infected person from others, reducing the risk of transmission.
Proper PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the infectious droplets, further minimizing the risk of spread.
Choice C rationale:
Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus. However, it is not as immediate a priority as isolating the client to prevent further transmission.
Choice D rationale:
Counseling family members about monitoring for symptoms is also important for early identification and containment of potential cases. However, it does not directly address the immediate risk of transmission from the actively symptomatic client.
Correct Answer is ["B","C","E","F","G"]
Explanation
The correct answer is choiceb. Identify the client using 2 client identifiers,c. Perform hand hygiene,e. Don gloves,f. Check the skin around the face, andg. Assess respiratory function.
Choice A rationale:
Determining if the client needs to go to the bathroom is not directly related to the immediate preparation for oxygen administration. However, it can be considered as part of overall patient comfort and care.
Choice B rationale:
Identifying the client using 2 client identifiers is crucial to ensure the correct patient is receiving the correct treatment, which is a standard safety protocol in healthcare settings.
Choice C rationale:
Performing hand hygiene is essential to prevent the spread of infection and maintain a sterile environment.
Choice D rationale:
Brushing the client’s teeth is not a necessary step before applying a simple face mask for oxygen administration. It is more related to general oral hygiene.
Choice E rationale:
Donning gloves is important to protect both the nurse and the patient from potential contamination and infection.
Choice F rationale:
Checking the skin around the face is important to ensure there are no existing sores or irritations that could be exacerbated by the mask.
Choice G rationale:
Assessing respiratory function is critical to determine the patient’s baseline respiratory status and to monitor the effectiveness of the oxygen therapy.
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