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 A
Explanation
A. A possible airway obstruction: The tripod positionis a classic sign of epiglottitis and indicates the child is attempting to maximize airway patency. This posture helps keep the airway open and suggests significant upper airway obstruction, requiring immediate intervention.
B. The presence of pain: While children with epiglottitis often experience throat pain, this posture is not primarily used to relieve pain. It is associated with efforts to ease breathing and maintain airflow in the face of an obstructed or narrowed airway.
C. Extreme fatigue: Fatigue may occur in respiratory illnesses, but the tripod position is an active posture that requires muscle engagement. It is not a typical sign of fatigue and more accurately reflects respiratory distress and airway compromise.
D. Dehydration: Dehydration may be present in epiglottitis due to poor oral intake, but it does not cause the child to assume the tripod position. The posture is a compensatory mechanism for airway obstruction, not a direct result of fluid imbalance.
Correct Answer is A
Explanation
A. Assess the posterior pharynx for active bleeding:Frequent throat clearing without reported pain after a tonsillectomy may indicate active bleeding, which can be life-threatening. Silent bleeding may drip down the throat and trigger subtle clearing rather than coughing or spitting, making visual inspection an immediate priority.
B. Place the client in the side lying position:Side-lying can help prevent aspiration if bleeding occurs, but it does not replace the need to directly assess for bleeding first. Positioning should follow an initial airway and bleeding assessment.
C. Give the client juice through a straw:Using a straw is discouraged after tonsillectomy because the suction motion can disrupt clots and provoke bleeding. Juice may be appropriate for hydration, but not with a straw and not before checking for bleeding.
D. Offer the client ice cream to coat the throat:Cold soft foods like ice cream may soothe the throat and reduce swelling, but this should not be the first action when silent bleeding is suspected. The priority is ensuring that no active bleeding is occurring before offering food.
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