Exhibits
Which assessment finding is most concerning and requires immediate nursing intervention?
Blood pressure of 138/84 mmHg
WBC count of 15,000/mm
Blood glucose of 198 mg/dL
Oxygen saturation 89%
The Correct Answer is D
A. Blood pressure of 138/84 mmHg: This is within the acceptable range for a 68-year-old adult, especially with a history of hypertension. It does not indicate an acute threat or require immediate intervention in the context of pneumonia.
B. WBC count of 15,000/mm³: An elevated WBC count is expected in response to infection, such as pneumonia. While it confirms an inflammatory process, it is not the most urgent issue requiring immediate nursing action.
C. Blood glucose of 198 mg/dL: This mild hyperglycemia is not uncommon in infections and stress responses, particularly in patients with diabetes. It should be monitored, but it is not an immediate danger to the patient.
D. Oxygen saturation 89%: This low oxygen saturation indicates hypoxemia and impaired gas exchange, which is critical in a patient with pneumonia. Immediate oxygen therapy is necessary to prevent tissue hypoxia and respiratory failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer an NSAID for discomfort:While fever and discomfort may contribute to restlessness, NSAIDs do not address the most urgent concern, which is potential hypoxia. Treating symptoms without first assessing respiratory function may delay appropriate intervention.
B. Assess the patient's O₂ saturation:Increasing restlessness and confusion in a pneumonia patient can be early signs of hypoxia, especially in older adults. Oxygen saturation should be evaluated immediately to determine if the patient needs supplemental oxygen or further respiratory support.
C. Check the MAR for an order for a mild sedative:Sedatives may worsen confusion and can depress respiratory drive, particularly in hypoxic patients. Administering a sedative without first ruling out hypoxia may pose significant risk.
D. Take the patient off of oral fluids:Unless there are clear signs of aspiration or decreased level of consciousness, discontinuing oral fluids is not an appropriate first step. Hydration is important in pneumonia to help thin secretions and support recovery.
Correct Answer is A
Explanation
A. White blood cell (WBC) count, arterial blood gases (ABGs):WBC count helps assess the presence and severity of infection, while ABGs evaluate the patient’s oxygenation and gas exchange critical factors in pneumonia. These tests directly reflect respiratory function and the inflammatory response.
B. Complete blood count (CBC), urinalysis:While a CBC includes the WBC count, the rest of the values are not directly helpful in tracking pneumonia progression. A urinalysis assesses kidney and urinary tract health, not respiratory infection, so it is not essential.
C. Electrolytes, serum creatinine:These tests provide information on renal function and electrolyte balance, which may be relevant in complex cases but are not specific indicators of pneumonia status or treatment response.
D. Partial thromboplastin time (PTT), serum potassium:PTT evaluates clotting, and serum potassium assesses electrolyte balance. Neither test provides useful information about the progression or resolution of pneumonia.
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