A nurse implements a plan of care for a client with the problem of Impaired Gas Exchange as a result of left lower lobe pneumonia. Which findings would indicate that nursing interventions were successful? (Select all that apply)

Cyanosis noted in nail beds bilaterally.

Lungs clear to auscultation.

Inability to speak in full sentences.

Pulse oximetry 94-96% on room air.

Answer and Explanation

Correct Answer : B,D

Choice A reason:
Cyanosis, or a bluish discoloration of the skin, particularly in the nail beds, is a sign of inadequate oxygenation and would not indicate successful intervention. The absence of cyanosis would be a positive outcome, reflecting improved oxygen saturation.

Choice B reason:
Lungs clear to auscultation would indicate that air is moving through all regions of the lungs without obstruction from fluid or mucus, which is a sign of recovery from pneumonia. This finding suggests that the interventions aimed at improving gas exchange, such as positioning, deep breathing exercises, and suctioning if needed, have been effective.

Choice C reason: The inability to speak in full sentences often indicates respiratory distress and would not be a sign of successful nursing intervention. An improvement would be the client's ability to speak in full sentences without difficulty, reflecting better lung function and gas exchange.

Choice D reason:
Pulse oximetry readings between 94-96% on room air are within normal limits and indicate adequate oxygen saturation and gas exchange. This is a clear sign that the client's respiratory status has improved, and the interventions for Impaired Gas Exchange have been successful.

Choice E reason:
Bronchovesicular breath sounds are normal breath sounds heard over the major bronchi and are typically moderate in pitch and intensity. However, they are not specifically indicative of successful intervention for Impaired Gas Exchange. The absence of abnormal sounds such as crackles or wheezes would be more relevant.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A Reason
Hyperreflexia refers to an overactive or overresponsive reflexes, which is a neurological condition and not directly related to the behaviors described. It is typically seen in conditions affecting the central nervous system and is not characterized by the inability to wait turns or interrupting conversations.

Choice B Reason
Defiance implies a conscious choice to resist authority or rules, which may not necessarily be the case here. While children with behavioral issues may exhibit defiant behaviors, the symptoms described are more indicative of a lack of impulse control rather than a deliberate choice to defy.

Choice C Reason
Inattention is a component of several behavioral and cognitive disorders, including ADHD. However, the behaviors described—blurting out answers, inability to wait for turns, and interrupting others—are more specifically associated with impulsivity rather than inattention alone.

Choice D Reason
Impulsivity is the tendency to act on a whim, displaying behavior characterized by little or no forethought, reflection, or consideration of the consequences. The behaviors described—such as blurting out answers and interrupting others—are classic signs of impulsivity, which is often seen in conditions like ADHD.

A. Check blood glucose levels prior to exercising. B. Signs and symptoms of hypoglycemia. C. Weight control is necessary for this disease. D. Decrease fiber and protein in the diet. E. Obtain eye examinations every 3 months.

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

Explanation

Choice A Reason
Monitoring blood glucose levels before exercise is crucial for individuals with Type 2 diabetes. Exercise can lower blood glucose levels, and it's important to ensure they are not too low before starting, which could lead to hypoglycemia during physical activity. The patient should be taught how to check their glucose and understand their target ranges.

Choice B Reason
Recognizing the signs and symptoms of hypoglycemia is essential for all individuals with diabetes, especially those on medications that can lower blood glucose levels. Symptoms may include shakiness, sweating, confusion, and in severe cases, loss of consciousness. Patients should know how to respond to these symptoms promptly.

Choice C Reason
Weight control through diet and exercise is a fundamental part of managing Type 2 diabetes. A BMI of 28 falls into the overweight category, and reducing weight can help improve insulin sensitivity and blood glucose control. The patient should receive guidance on healthy eating and physical activity tailored to their needs.

Choice D Reason
Decreasing fiber and protein in the diet is not recommended for individuals with Type 2 diabetes. In fact, a diet high in fiber can help control blood sugar levels, and adequate protein intake is important for overall health. Patients should be encouraged to consume a balanced diet with sufficient fiber and protein.

Choice E Reason
While regular eye examinations are important for individuals with diabetes, obtaining them every 3 months is not typically necessary unless there is an existing eye condition that requires close monitoring. Generally, an annual eye exam is recommended to check for diabetes-related eye complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse implements a plan of care for a client with the problem of Impaired Gas Exchange as a result of left lower lobe pneumonia. Which findings would indicate that nursing interventions were successful? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Assessment data for a 9-year-old reveals that she blurts out answers to questions before the question is completed, is unable to wait her turn, and persistently interrupts and intrudes in the conversations of others. The nurse would assess these behaviors as relating primarily to:

Correct Answer is D

Explanation

For a client newly diagnosed with Type 2 diabetes mellitus who has a BMI index of 28, which information should the nurse include in the teaching plan? (Select all that apply)

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

Explanation

The nurse is preparing to hang the client's next bag of Total Parenteral Nutrition (TPN) and observes fat globules rising to the top of the solution. What action should the nurse take?

A client diagnosed with depression expresses a preference for alternative therapy over prescription medication. Which alternative therapy has been shown to be effective in treating this client's condition?

The nurse is providing discharge teaching to a client newly diagnosed with hypertension. Which food item(s) should the nurse instruct the client to avoid in order to assist In controlling the blood pressure? (SELECT ALL THAT APPLY)

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

The nurse is caring for a client who is two days post-aortic-iliac bypass surgery. Which assessment finding should be reported to the surgeon immediately?

The nurse is providing discharge teaching to a client with angina pectoris who is prescribed metoprolol 50 mg PO daily. Which information should the nurse include in the teaching?

A client was admitted to the emergency department with slurred speech and impaired motor coordination. The blood alcohol level is over 300 mg/dL. The physician orders thiamine for the client. The nurse understands that the physician ordered thiamine to:

A nurse is discussing fibromyalgia with a client who is concerned about developing the disorder. Which finding would the nurse identify as a risk factor for this disease?