A client with left lower lobe pneumonia has activity intolerance related to impaired oxygen supply and demand as evidenced by fatigue, dyspnea, and difficulty performing self-care. Which expected outcome must be included in the care plan related to this problem? The client will:

Have a pulse oximetry reading of 95% or greater by discharge.

Exhibit a respiratory rate of 12-20/minute by discharge.

Perform self-care activity without dyspnea by discharge.

Have clear breath sounds bilaterally by discharge.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Have a pulse oximetry reading of 95% or greater by discharge: While maintaining a pulse oximetry reading of 95% or greater is important, it may not fully address the client’s activity intolerance. Pulse oximetry measures the oxygen saturation in the blood, and normal readings typically range from 95% to 100%. However, achieving this reading alone does not ensure that the client can perform activities without experiencing dyspnea or fatigue.

Choice B reason:

Exhibit a respiratory rate of 12-20/minute by discharge: A normal respiratory rate for adults is between 12 and 20 breaths per minute. While this is a good indicator of respiratory function, it does not directly address the client’s ability to perform self-care activities without dyspnea. The goal should focus on the client’s functional ability rather than just physiological parameters.

Choice C reason:

Perform self-care activity without dyspnea by discharge: This outcome directly addresses the client’s activity intolerance. Dyspnea, or difficulty breathing, is a significant symptom that affects the client’s ability to perform daily activities. By setting a goal for the client to perform self-care activities without dyspnea, the care plan focuses on improving the client’s functional status and quality of life.

Choice D reason:

Have clear breath sounds bilaterally by discharge: Clear breath sounds are an important indicator of improved lung function and resolution of pneumonia. However, this outcome does not specifically address the client’s activity intolerance. While clear breath sounds are desirable, the primary goal should be to ensure the client can perform activities without experiencing dyspnea.

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Correct Answer is D

Explanation

Early signs of hypoxia, which is a condition where the body or a region of the body is deprived of adequate oxygen supply, often include symptoms such as restlessness, confusion, and tachycardia (rapid heart rate). These symptoms occur because the body is trying to compensate for the lack of oxygen by increasing heart rate and causing a state of agitation or confusion.

Choice A reason:

Bradycardia, lethargy, confusion are not typically early signs of hypoxia. Bradycardia (slow heart rate) is more commonly associated with severe or prolonged hypoxia rather than early stages. Lethargy and confusion can occur, but they are not as immediate as restlessness and tachycardia.

Choice B reason:

Hypotension, vomiting, cyanosis are also not early signs of hypoxia. Hypotension (low blood pressure) and cyanosis (bluish discoloration of the skin) are more advanced signs indicating severe hypoxia. Vomiting is not a common symptom of hypoxia and is more likely related to other conditions.

Choice C reason:

Bradycardia, dyspnea, cyanosis includes symptoms that are more indicative of advanced hypoxia. Dyspnea (difficulty breathing) and cyanosis are signs that the body has been deprived of oxygen for a longer period. Bradycardia is not an early sign and usually occurs later in the progression of hypoxia.

Choice D reason:

Restlessness, confusion, tachycardia are classic early signs of hypoxia. Restlessness and confusion occur due to the brain’s response to low oxygen levels, while tachycardia is the body’s attempt to increase oxygen delivery to tissues by pumping blood more rapidly. These symptoms are the body’s initial compensatory mechanisms to address the lack of oxygen.

Correct Answer is ["0.5"]

Explanation

Step 1: Convert the prescribed dose from mcg to mg.

235 mcg ÷ 1000 = 0.235 mg

Step 2: Determine the strength of the available tablet.

Available strength = 0.5 mg per tablet

Step 3: Calculate the number of tablets needed.

Number of tablets = 0.235 mg ÷ 0.5 mg/tablet

Step 4: Perform the division.

0.235 ÷ 0.5 = 0.47

Step 5: Round the answer to the nearest tenth.

0.47 rounded to the nearest tenth = 0.5

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A client with left lower lobe pneumonia has activity intolerance related to impaired oxygen supply and demand as evidenced by fatigue, dyspnea, and difficulty performing self-care. Which expected outcome must be included in the care plan related to this problem? The client will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse recognizes that the client is manifesting early signs of hypoxia with findings of:

Correct Answer is D

Explanation

A nurse is caring for a client prescribed drug N 235 mcg PO daily. Available is drug N PO 0.5 mg per 1 scored tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.5"]

Explanation

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