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A patient's data shows consolidation in the right middle and lower lobe, consistent with pneumonia.
What actions can the nurse take to assist the patient in improving their ventilation and oxygenation? Select all that apply.

Provide suctioning so the patient does not have to cough.

Position the patient with the head of the bed elevated.

Encourage the patient to take breaks from the oxygen mask every few hours.

Ask the patient to do quick, shallow breaths.

Teach the patient to cough at least once an hour.

Avoid treating fever with antipyretics.

Assist the patient in ambulating safely.

Answer and Explanation

Correct Answer : B,E,G

B. Position the patient with the head of the bed elevated. Rationale:

Promotes lung expansion: Elevating the head of the bed by at least 30 degrees utilizes gravity to assist in diaphragmatic descent and lung expansion. This allows for greater intake of air, optimizing oxygen intake and facilitating better gas exchange.

Reduces work of breathing: When upright, the abdominal muscles can more effectively aid in breathing, reducing the workload on the diaphragm and accessory muscles. This conserves energy and decreases the patient's respiratory effort.

Enhances secretion drainage: Gravity also aids in the movement of secretions from the lower lobes of the lungs towards the upper airways, where they can be more easily coughed up or suctioned. This helps to clear the airways and improve ventilation.

E. Teach the patient to cough at least once an hour. Rationale:

Clears secretions: Coughing is a natural mechanism to clear secretions from the lungs and airways. It helps to prevent mucus buildup and potential obstruction, which can lead to atelectasis (collapse of lung tissue) and further compromise ventilation.

Improves gas exchange: By removing secretions, coughing allows for better airflow and gas exchange within the lungs. This enhances oxygenation and helps to prevent respiratory complications.

G. Assist the patient in ambulating safely. Rationale:

Mobilizes secretions: Ambulation encourages movement of secretions from the lower lobes of the lungs, promoting their clearance and preventing mucus buildup.

Prevents atelectasis: Walking and movement help to expand the lungs, reducing the risk of atelectasis and improving overall ventilation.

Enhances circulation: Ambulation also improves circulation, which can help to deliver oxygen to the tissues more effectively and aid in healing.

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Correct Answer is A

Explanation

Choice A rationale:

Direct identification of the causative organism: A culture for sensitive organisms is the most direct and definitive way to identify the specific bacteria or other microorganisms that are causing the infection in the wound. This information is crucial for guiding the selection of the most appropriate antibiotic therapy.

Tailored antibiotic therapy: By knowing the exact organism responsible, healthcare providers can prescribe antibiotics that are specifically effective against that organism, ensuring optimal treatment and reducing the risk of antibiotic resistance.

Informed infection control measures: The results of the culture can also inform appropriate infection control measures to prevent the spread of the infection to other patients or healthcare workers.

Monitoring treatment effectiveness: Cultures can also be used to monitor the effectiveness of antibiotic therapy. If the culture results show that the bacteria are no longer present after a course of antibiotics, this indicates that the treatment has been successful.

Choice B rationale:

Non-specific marker of inflammation: C-reactive protein (CRP) is a non-specific marker of inflammation that can be elevated in various conditions, including infections, but also in non-infectious conditions such as autoimmune diseases and trauma.

Limited diagnostic value for wound infections: While an elevated CRP level may suggest the presence of an infection, it does not provide information about the specific causative organism, which is essential for guiding antibiotic therapy.

Supplementary role: CRP levels can be used in conjunction with other clinical findings and laboratory tests to assess the severity of an infection and monitor the response to treatment, but it should not be relied upon as a sole diagnostic tool for wound infections.

Choice C rationale:

Not directly indicative of wound infection: Blood pH level primarily reflects the acid-base balance of the body and is not directly indicative of a wound infection.

Alterations in other conditions: Blood pH can be altered in various conditions, including respiratory and metabolic disorders, and is not specific to wound infections.

Limited role in diagnosis: While significant alterations in blood pH may suggest a serious systemic infection, it does not provide information about the location or causative organism of the infection.

Choice D rationale:

Not directly related to wound infection: Serum blood glucose level is primarily used to monitor diabetes and is not directly related to wound infections.

Impaired wound healing in diabetes: While elevated blood glucose levels can impair wound healing and increase the risk of infections in diabetic patients, it is not a diagnostic test for wound infections in general.

Secondary consideration: Blood glucose levels may be considered as part of the overall assessment of a patient with a wound infection, particularly in those with diabetes, but it is not a primary diagnostic tool.

A. Improved mental status. B. Increase in urine output. C. Reduction in number of liquid stools. D. Ability to ambulate independently.

Correct Answer is A

Explanation

Choice A rationale:

Lactulose is a non-absorbable disaccharide that is metabolized by bacteria in the colon to produce lactic acid and acetic acid. These acids acidify the colon, which traps ammonia (NH3) in the colon and converts it to ammonium (NH4+). Ammonium is not absorbed by the colon and is excreted in the stool. This ammonia-lowering effect is the primary mechanism by which lactulose improves mental status in patients with hepatic encephalopathy.

Hepatic encephalopathy is a neuropsychiatric syndrome that occurs in patients with severe liver disease. It is caused by the buildup of ammonia in the blood, which can cross the blood-brain barrier and cause cerebral edema and impaired brain function.

The clinical manifestations of hepatic encephalopathy range from mild confusion and personality changes to coma. Improved mental status is a key therapeutic goal in the treatment of hepatic encephalopathy.

Studies have shown that lactulose can improve mental status in patients with hepatic encephalopathy. A meta-analysis of 11 randomized controlled trials found that lactulose was associated with a significant improvement in mental status compared to placebo.

The improvement in mental status is typically seen within 24 to 48 hours of starting lactulose therapy.

Choice B rationale:

Increased urine output is not a direct therapeutic effect of lactulose. Lactulose can cause diarrhea, which can lead to increased urine output due to fluid loss. However, this is not the primary mechanism by which lactulose improves mental status in patients with hepatic encephalopathy.

Choice C rationale:

Reduction in the number of liquid stools is a common side effect of lactulose. However, it is not a therapeutic goal in the treatment of hepatic encephalopathy. The goal of lactulose therapy is to improve mental status by lowering ammonia levels in the blood.

Choice D rationale:

Ability to ambulate independently is not a direct therapeutic effect of lactulose. Lactulose can improve mental status, which may indirectly lead to improved ambulation in some patients. However, this is not the primary mechanism by which lactulose works.

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A patient's data shows consolidation in the right middle and lower lobe, consistent with pneumonia. What actions can the nurse take to assist the patient in improving their ventilation and oxygenation? Select all that apply.

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Naxlex Comprehensive Predictor Exams

While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound.Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

Correct Answer is A

Explanation

A client has been administered lactulose for several days.Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

Correct Answer is A

Explanation

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A patient's data shows consolidation in the right middle and lower lobe, consistent with pneumonia.
What actions can the nurse take to assist the patient in improving their ventilation and oxygenation? Select all that apply.