A nurse is collecting data on a client who has pneumonia. Which of the following findings should the nurse expect?
Hypothermia
Bradycardia
Pulse deficit
Tachypnea
The Correct Answer is D
A. Hypothermia: Pneumonia typically presents with fever rather than hypothermia. Fever is a common response to infection and inflammation.
B. Bradycardia: Pneumonia usually causes tachycardia rather than bradycardia. Tachycardia is a compensatory response to improve oxygen delivery to tissues.
C. Pulse deficit: A pulse deficit is not a common finding in pneumonia. It is more associated with conditions like atrial fibrillation.
D. Tachypnea: Tachypnea, or rapid breathing, is a common sign of pneumonia. It reflects the body’s attempt to improve oxygenation and compensate for impaired gas exchange.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
A. Repeat blood serum potassium: While it’s important to monitor potassium levels, the immediate priority when preparing to administer potassium is ensuring safe administration practices, not rechecking levels before initiating therapy.
B. Educate client regarding high-potassium food sources: Client education is important for long-term management but is not a priority when preparing for intravenous potassium replacement in an acute setting.
C. Cardiac monitoring during infusion: Potassium affects cardiac conduction, and rapid correction can lead to arrhythmias. Continuous cardiac monitoring is necessary to detect any life-threatening arrhythmias during the infusion.
D. Ensure that the client's urine output is at least 1 mL/kg/hour: Adequate urine output ensures that the kidneys are functioning and capable of excreting excess potassium, reducing the risk of hyperkalemia.
E. Ensure potassium infusion is prepared with 5% dextrose solution: Potassium should not be mixed with dextrose, as it can increase insulin release, causing potassium to shift into cells and worsen hypokalemia.
Correct Answer is D
Explanation
A. Impaired carbon dioxide elimination due to shunting: In ARDS, shunting can impair oxygenation but not directly carbon dioxide elimination. Shunting refers to blood flow through areas of the lung that are not ventilated properly, primarily affecting oxygenation.
B. Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch: ARDS is typically associated with increased, not decreased, pulmonary arterial pressure due to the inflammatory process and reduced lung compliance. V/Q mismatch in ARDS usually results in elevated pulmonary arterial pressure.
C. Hypoxemia due to dead space: ARDS hypoxemia results from impaired gas exchange in damaged alveoli rather than dead space, which is more related to ventilation without perfusion.
D. Decreased pulmonary compliance due to stiffness: ARDS is characterized by decreased pulmonary compliance, which is due to the stiffening of lung tissue from inflammation and edema. This stiffness makes lung expansion more difficult and is a key feature of ARDS.
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