A nurse is caring for a client in an acute care setting.
The client is at risk for ________ as evidences by __________.
Complete the following sentence by using the list of options. Pick 2 choices.
Hypostatic pneumonia.
Anemia.
Fluid volume overload.
Immobility.
Calorie deficiency.
Correct Answer : A,D
Hypostatic Pneumonia Hypostatic pneumonia is a type of pneumonia that occurs when fluid or secretions settle in the lower lobes of the lungs, typically due to a lack of movement or staying in one position for too long. In this case, the client has paraplegia, which is a form of significant immobility. This condition prevents the client from effectively clearing their airway and results in decreased lung expansion.
Analysis of Evidence The clinical findings on Day 2 clearly indicate a progression toward an infectious respiratory process caused by this immobility:
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Respiratory Status: The oxygen saturation has dropped from 95% to 89%, and the respiratory rate has increased from 20/min to 24/min (tachypnea).
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Symptoms: The client has transitioned from a simple cough to a productive cough and is now experiencing confusion, which is a common sign of hypoxia in clinical settings.
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Infection Markers: The client's temperature has risen to 38.4°C (101.1°F), and the WBC count is elevated at 12,500/mm³, indicating a systemic inflammatory response or infection.
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Tachycardia: The heart rate has increased to 105/min, which is a compensatory mechanism for decreased oxygenation and the presence of a fever.
While the client's Hgb is slightly low (11.0 g/dL), it does not explain the acute onset of fever, confusion, and productive cough. Furthermore, there are no signs of fluid volume overload (such as edema or high BP) or calorie deficiency that would trigger these specific respiratory and febrile symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Including any adverse effects of the medications the client might develop is important but does not cover the entire scope of medication reconciliation. It is essential to compare new prescriptions with the list of current medications to prevent drug interactions, duplications, or omissions.
Choice B rationale:
Comparing new prescriptions with the list of medications the client reports is the correct approach to medication reconciliation. This helps identify discrepancies, ensuring that the client's current medications are accurately documented and preventing medication errors.
Choice C rationale:
Excluding nutritional supplements from the list of medications the client reports is incorrect. Nutritional supplements, herbal remedies, and over-the-counter medications are essential components of the medication list. These items can interact with prescribed medications and affect the client's overall health.
Choice D rationale:
Encouraging the client to make his own list after he returns home is not recommended. Patients might not have complete knowledge of the medications they are taking, including dosages and frequencies. Relying solely on the patient-generated list can lead to inaccuracies and potential harm.
Correct Answer is D
Explanation
Choice A rationale:
Taking antibiotics when having a virus is not a correct understanding of infection prevention. Antibiotics are ineffective against viruses and should only be used for bacterial infections under the guidance of a healthcare provider. This statement indicates a misunderstanding of infection prevention.
Choice B rationale:
Washing hands for at least 20 seconds with soap and water is the recommended practice for infection prevention. Washing hands for 10 seconds may not be sufficient to remove all germs effectively. This statement does not demonstrate a proper understanding of hand hygiene.
Choice C rationale:
Cleaning a cat's litter box during pregnancy is not recommended due to the risk of contracting toxoplasmosis, a parasitic infection that can harm the fetus. Pregnant individuals should avoid handling cat litter to prevent exposure to this infection. This statement indicates a lack of awareness regarding infection prevention during pregnancy.
Choice D rationale:
Waiting 5 days after the chickenpox sores have crusted before visiting a person with chickenpox demonstrates an understanding of infection prevention. Chickenpox is highly contagious, and individuals should avoid close contact until the sores have fully healed and crusted over. This statement reflects appropriate knowledge about preventing the spread of contagious diseases during pregnancy.
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