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 C
Explanation
A. Nasal cannula:The nasal cannula provides low-flow oxygen with variable concentrations depending on the patient's respiratory rate and tidal volume. It does not deliver a precise or consistent oxygen concentration.
B. Simple face mask:The simple face mask delivers moderate concentrations of oxygen, generally between 40–60%, but it lacks a mechanism for precise control. Oxygen delivery fluctuates based on the patient’s breathing pattern and flow rate.
C. Venturi mask:The Venturi mask is designed to deliver a specific and consistent concentration of oxygen by using color-coded adaptors that mix oxygen with room air at fixed ratios. This makes it ideal for patients who require accurate oxygen titration, such as those with COPD.
D. Non-rebreather mask:A non-rebreather mask delivers high concentrations of oxygen (up to 90–100%) but does not allow for fine control of the exact oxygen percentage. It is used in emergencies when high oxygen delivery is needed, not for precise regulation.
Correct Answer is ["A","B","D","E"]
Explanation
A. Perform suction with sterile supplies:Sterile technique is essential when suctioning a tracheostomy to prevent introducing pathogens into the lower airway. Sterile supplies and gloves help reduce the risk of infection in this direct airway access point.
B. Auscultate lungs for retained secretions:Before suctioning, the nurse should assess for signs that suctioning is needed, such as abnormal breath sounds (e.g., crackles, rhonchi) that indicate secretion buildup in the airways.
C. Don clean gloves and lift out catheter and connect to suction:Clean gloves are insufficient for the suctioning procedure. This is an invasive technique involving direct access to the lower airway, requiring sterile gloves and equipment to prevent infection.
D. Wash hands and open sterile suction kit:Hand hygiene is a fundamental part of infection control. Opening the sterile suction kit properly maintains the sterility of equipment needed for the procedure.
E. Inform the patient about the procedure:Providing a brief explanation prepares the patient, reduces anxiety, and promotes cooperation. Even if the patient is nonverbal, communication is part of professional and ethical nursing care.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.