A nurse is planning care for an adolescent who was admitted from the emergency department.
Complete the diagram by dragging from the choices below to specify what condition the client is likely experiencing, 2 actions the nurse should take to address the condition, and 2 parameters the nurse should monitor to assess the client’s progress
The Correct Answer is []
Potential Condition: Viral Pneumonia
High fever (39.88°C/103.8°F), severe fatigue, chills, productive cough, and dyspnea suggest a respiratory infection. Bilateral lung consolidation on x-ray is consistent with viral pneumonia. Negative bacterial culture supports a viral rather than bacterial etiology. Elevated WBC count (12,300/mm³) is slightly above normal, which can occur with viral infections. Crackles in upper lobes, diminished breath sounds in lower lobes are common findings in pneumonia.
Actions to Take (Correct Choices)
Cluster client care to allow for rest: Viral pneumonia leads to fatigue and respiratory distress. Minimizing exertion conserves energy and improves recovery.
Administer prescribed antipyretic: Reduces fever, improves comfort, and helps decrease metabolic demand on the body.
Incorrect Actions and Rationale:
Replace pancreatic enzymes – This is necessary for cystic fibrosis, not viral pneumonia.
Maintain airborne precautions – Airborne precautions are required for tuberculosis (TB), not viral pneumonia. Pneumonia typically requires droplet precautions only if caused by a pathogen like influenza.
Obtain a peak respiratory flow rate – More relevant for asthma, not pneumonia.
Parameters to Monitor (Correct Choices)
Level of fatigue: Fatigue indicates worsening illness or improvement. Increasing exhaustion may suggest hypoxia or worsening pneumonia.
Oxygen saturation levels: 92% on room air is borderline low, requiring monitoring for worsening hypoxemia. Oxygen therapy may be needed if saturation drops further.
Incorrect Parameters:
Allergen triggers – Relevant for asthma, not viral pneumonia.
Diet high in protein and calcium – Important for cystic fibrosis, but not a primary concern for pneumonia management.
Blood glucose levels – More relevant for diabetes or steroid therapy, not viral pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Potential Condition: Viral Pneumonia
High fever (39.88°C/103.8°F), severe fatigue, chills, productive cough, and dyspnea suggest a respiratory infection. Bilateral lung consolidation on x-ray is consistent with viral pneumonia. Negative bacterial culture supports a viral rather than bacterial etiology. Elevated WBC count (12,300/mm³) is slightly above normal, which can occur with viral infections. Crackles in upper lobes, diminished breath sounds in lower lobes are common findings in pneumonia.
Actions to Take (Correct Choices)
Cluster client care to allow for rest: Viral pneumonia leads to fatigue and respiratory distress. Minimizing exertion conserves energy and improves recovery.
Administer prescribed antipyretic: Reduces fever, improves comfort, and helps decrease metabolic demand on the body.
Incorrect Actions and Rationale:
Replace pancreatic enzymes – This is necessary for cystic fibrosis, not viral pneumonia.
Maintain airborne precautions – Airborne precautions are required for tuberculosis (TB), not viral pneumonia. Pneumonia typically requires droplet precautions only if caused by a pathogen like influenza.
Obtain a peak respiratory flow rate – More relevant for asthma, not pneumonia.
Parameters to Monitor (Correct Choices)
Level of fatigue: Fatigue indicates worsening illness or improvement. Increasing exhaustion may suggest hypoxia or worsening pneumonia.
Oxygen saturation levels: 92% on room air is borderline low, requiring monitoring for worsening hypoxemia. Oxygen therapy may be needed if saturation drops further.
Incorrect Parameters:
Allergen triggers – Relevant for asthma, not viral pneumonia.
Diet high in protein and calcium – Important for cystic fibrosis, but not a primary concern for pneumonia management.
Blood glucose levels – More relevant for diabetes or steroid therapy, not viral pneumonia.
Correct Answer is C
Explanation
A. Transposition of The Great Arteries involves abnormal positioning of the arteries, leading to systemic and pulmonary circulations being disconnected, rather than increased pulmonary blood flow.
B. Coarctation of the Aorta is a narrowing of the aorta that can cause increased pressure in the upper extremities but does not involve increased pulmonary blood flow.
C. Patent Ductus Arteriosus (PDA) is a condition where the ductus arteriosus fails to close, causing increased blood flow to the lungs, leading to pulmonary overcirculation.
D. Tetralogy of Fallot leads to decreased pulmonary blood flow due to pulmonary stenosis and right ventricular hypertrophy.
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