A patient is admitted to a respiratory unit with a diagnosis of bacterial pneumonia. Findings include a fever and a weak, congested-sounding cough with moist crackles throughout the lung fields. How should the nurse prioritize care?

Difficulty with breathing

Inability to clear the airway

Confusion from fever

Inadequate oxygen level

Answer and Explanation

The Correct Answer is B

B. The inability to clear the airway is a critical issue. This patient has a weak, congested-sounding cough and moist crackles, indicating that secretions are present and not being effectively cleared. This can lead to airway obstruction, decreased oxygenation, and further respiratory complications. Clearing the airway is a top priority to ensure the patient can breathe properly and prevent further deterioration.
A. Difficulty breathing (dyspnea) is a serious concern as it can indicate respiratory distress or failure. However, it is often a symptom rather than a primary issue, and its underlying causes (such as an inability to clear the airway or inadequate oxygen levels) must be addressed first.
C. Confusion can result from high fever, infection, or hypoxia. While it is important to address the fever and its underlying cause, confusion itself is usually a secondary issue. Addressing the primary respiratory issues will often improve the patient's mental status as well.
D. Hypoxia can result from severe pneumonia, and resolving it involves ensuring the patient has a clear airway and adequate ventilation. Measuring and correcting oxygen levels (e.g., with supplemental oxygen) is crucial, but the underlying cause (such as airway obstruction) must also be managed.

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Correct Answer is C

Explanation

C. Persistent shortness of breath after using an inhaler could indicate an inadequate response to treatment or worsening asthma exacerbation. The nurse should therefore see this patient first.
A. In COPD patients pulse oximetry oxygen saturations of more than 90% are acceptable. In the treatment of exacerbations of chronic obstructive pulmonary disease (COPD), oxygen should be titrated to achieve a target oxygen saturation range of 88-92%. This results in a greater than twofold reduction in mortality, compared with the routine administration of high-concentration oxygen therapy.
B. Administering antibiotics can be prioritized, but it may not require immediate attention compared to addressing acute respiratory distress or hypoxemia.
D. Collecting a sputum specimen for laboratory analysis is important for diagnosing and managing respiratory infections, but it may not be as time-sensitive as addressing acute respiratory distress or hypoxemia.

A. At bedtime B. In the morning C. After meals D. After start of antibiotics

Correct Answer is B

Explanation

B. Morning is considered the ideal time for collecting a sputum specimen. Overnight, mucus accumulates in the respiratory tract because the patient is less active and not clearing their throat or coughing as much. This means that the mucus is more concentrated and has had time to build up, providing a more substantial and representative sample of what is in the lungs.
A. Collecting a sputum specimen at bedtime is generally not ideal. By the end of the day, the patient’s respiratory tract might have cleared some of the accumulated mucus naturally through coughing or other activities.
C. Collecting a sputum specimen after meals is not recommended. Eating can introduce food particles and bacteria from the mouth into the sputum, contaminating the sample.
D. Starting antibiotics before collecting a sputum specimen can alter the bacterial flora present in the respiratory tract. This can lead to a false-negative result or an inaccurate representation of the pathogens causing the infection.

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A patient is admitted to a respiratory unit with a diagnosis of bacterial pneumonia. Findings include a fever and a weak, congested-sounding cough with moist crackles throughout the lung fields. How should the nurse prioritize care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After change of shift, the nurse has the following patients on her assignment. Which one should she see first?

Correct Answer is C

Explanation

Which time would be ideal for the LPN/LVN to collect a sputum specimen?

Correct Answer is B

Explanation

A patient is admitted to a respiratory unit with a diagnosis of bacterial pneumonia. Findings include a fever and a weak, congested-sounding cough with moist crackles throughout the lung fields. How should the nurse prioritize care?

Which patient does the LPN/LVN identify at high risk for hospital-acquired pneumonia?

The nurse is evaluating the knowledge of a patient recently diagnosed with type 1 DM. Which statement by the patient indicates a need for additional information?

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A nurse is reinforcing dietary teaching with a client who has GERD. Which of the following food choices by the client indicates an understanding of the teaching?

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