A client is admitted with the diagnosis of Pneumocystis carinii peneumonia. Which nursing diagnosis has the highest priority?

Impaired oral mucous membranes

Impaired gas exchange

Imbalanced nutrition: less than body requirements

Activity intolerance

Answer and Explanation

The Correct Answer is B

A. Impaired oral mucous membranes: Although oral mucosa may be affected in some conditions, this is not the priority diagnosis for a patient with Pneumocystis carinii pneumonia (PCP). The primary concern is the respiratory system, as PCP leads to severe difficulty breathing and impaired gas exchange.

B. Impaired gas exchange: Impaired gas exchange is the most critical priority because Pneumocystis carinii pneumonia primarily affects the lungs, leading to hypoxemia, respiratory distress, and compromised oxygen exchange. Addressing this is the immediate priority to ensure adequate oxygenation and prevent respiratory failure.

C. Imbalanced nutrition: less than body requirements: While nutrition is important, it is not the priority over airway and breathing concerns. Malnutrition may occur as a result of the disease or other factors, but it is secondary to ensuring adequate oxygenation and supporting respiratory function.

D. Activity intolerance: Although activity intolerance may be present in patients with Pneumocystis carinii pneumonia due to respiratory distress, it is less urgent compared to ensuring adequate gas exchange and stabilizing the patient's respiratory status.

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Correct Answer is C

Explanation

A. Hypertension: In hypovolemic shock, the body’s compensatory mechanisms initially try to maintain blood pressure, but as the shock worsens and blood volume continues to decrease, blood pressure typically drops causing hypotension rather than increases. Therefore, hypertension is not an expected finding.

B. Flushing of the skin: Flushing of the skin is more commonly associated with conditions like fever or septic shock, not hypovolemic shock. In hypovolemic shock, the skin may appear cool, pale, and clammy due to reduced perfusion.

C. Oliguria: Oliguria, or reduced urine output, is a common finding in hypovolemic shock. Decreased blood volume leads to decreased renal perfusion, and the kidneys conserve fluid by reducing urine output, which is an expected compensatory mechanism in response to shock.

D. Bradypnea: In hypovolemic shock, the body typically increases respiratory rate (tachypnea) to compensate for the low oxygen levels due to reduced perfusion, not bradypnea (slow breathing). Therefore, bradypnea is not an expected finding in hypovolemic shock.

A. Apply compression stockings B. Ambulate the client early C. Administer aspirin and warfarin D. Maintain the head of the bed at 90 degrees E. Encourage client to do active leg exercises

Correct Answer is ["A","B","E"]

Explanation

A. Apply compression stockings: Compression stockings help improve venous return and prevent blood stasis in the lower extremities, which is a major risk factor for deep vein thrombosis (DVT) and pulmonary embolism.

B. Ambulate the client early: Early ambulation is one of the most effective ways to reduce the risk of venous thromboembolism, including pulmonary embolism, by promoting circulation and preventing blood stasis.

C. Administer aspirin and warfarin: While anticoagulants such as warfarin may be used in certain high-risk patients, they are not typically prescribed immediately postoperatively unless indicated by specific risk factors.

D. Maintain the head of the bed at 90 degrees: Keeping the head of the bed at 90 degrees does not directly impact the risk of pulmonary embolism. It is more important to maintain the head of the bed at 30-45 degrees to promote comfort and prevent complications like deep vein thrombosis or respiratory distress.

E. Encourage client to do active leg exercises: Active leg exercises, such as ankle pumps, help stimulate circulation and reduce the risk of blood clots, which can ultimately decrease the risk of pulmonary embolism.

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A client is admitted with the diagnosis of Pneumocystis carinii peneumonia. Which nursing diagnosis has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Correct Answer is C

Explanation

A nurse is working on a surgical unit and is caring for a client who returned from the Post Anesthesia Care Unit (PACU) 90-minutes ago. Which interventions will decrease the client's risk of developing a pulmonary embolism? (Select All that Apply.)

Correct Answer is ["A","B","E"]

Explanation

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