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. “I must take insulin pills for the rest of my life." B. “I will count my carbohydrates at each meal and snack." C. “I will monitor my feet carefully every day." D. "I will try to keep my blood glucose between 80 and 130 mg/dL before meals."

Correct Answer is A

Explanation

A. Insulin is typically administered via injections or an insulin pump, not in pill form. Individuals with type 1 diabetes require exogenous insulin to manage their blood sugar levels because their pancreas does not produce insulin.
B. Carbohydrate counting is a fundamental skill for individuals with diabetes, as it allows them to adjust their insulin dosage to match their carbohydrate intake, thereby helping to manage blood sugar levels.
C. Regular foot monitoring is crucial for individuals with diabetes, as they are at increased risk of developing foot problems due to nerve damage (neuropathy) and poor circulation.
D. Maintaining blood glucose levels within the target range (80-130 mg/dL before meals) helps reduce the risk of both short-term complications (e.g., hypoglycemia) and long-term complications (e.g., neuropathy, retinopathy) associated with diabetes.

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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

The nurse knows a patient with type 1 diabetes needs more education when the patient makes which of the following statements?

Correct Answer is A

Explanation

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?

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

The nurse is preparing to teach about the long-term complications for patients diagnosed with diabetes. Which finding is accurate?

The nurse enters a room of a patient who is acutely short of breath. Which action should the nurse take first?

What type of cells secrete insulin?

The LPN/LVN is providing teaching for a patient with type 2 diabetes. Which statement indicates an understanding by the patient?

A nurse is preparing to administer liquid famotidine 20 mg PO every 6 hr for GERD. Available is famotidine 40 mg/5 mL. How many mL 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.)