Patient Data

Exhibits

The nurse is planning care for the client

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

The nurse should:

Raise the head of the bed to aid in breathing.
Change to a face mask for oxygen delivery to address hypoxia.

The nurse should monitor:

Lung sounds to assess the progression of pneumonia.
Oxygen saturation to ensure the patient is receiving adequate oxygen.

Choice A reason: Increasing IV fluids is important in the care of pneumonia patients to prevent dehydration, especially if the patient has fever and increased respiratory rate which can lead to fluid loss. However, in this case, the patient’s blood pressure is stable, and there is no indication of dehydration, so this would not be the immediate action.

Choice B reason: Raising the head of the bed can help improve the patient’s breathing by reducing pressure on the chest and aiding in lung expansion. This is a standard care practice for patients with respiratory difficulties and is particularly beneficial for those with pneumonia to facilitate easier breathing.

Choice C reason: Bronchodilator nebulization can help open airways and improve breathing in patients with respiratory conditions. While it may be used in the treatment of pneumonia, it is not the primary intervention for hypoxia.

Choice D reason: Changing to a face mask for oxygen delivery is a critical intervention for a patient experiencing hypoxia. The patient’s oxygen saturation is 88% on 2 L/minute via nasal cannula, which is below the normal range of 95-100%3. A face mask can deliver higher concentrations of oxygen, which is necessary to address the patient’s hypoxia.

Choice E reason: Calling a rapid response team is necessary if the patient’s condition is deteriorating rapidly and requires immediate medical intervention. In this scenario, while the patient is hypoxic, there is no indication of acute decompensation that would necessitate a rapid response team at this moment.

Choice F reason: Pneumothorax, or collapsed lung, would present with sudden chest pain and shortness of breath. The patient’s history and symptoms are more consistent with pneumonia rather than pneumothorax.

Choice G reason: Hypoventilation refers to decreased breathing efficiency, leading to increased levels of carbon dioxide in the blood. While the patient does have difficulty breathing, the primary issue seems to be the impaired oxygen exchange due to pneumonia, rather than hypoventilation.

Choice H reason: Atelectasis is the collapse of part of the lung, which can occur after surgery or with bedridden patients. This patient’s symptoms are more indicative of an infectious process rather than atelectasis.

Choice I reason: Hypoxia is a condition where the body or a region of the body is deprived of adequate oxygen supply. Given the patient’s low oxygen saturation level and bilateral lower lobe pneumonia, hypoxia is the most likely condition the patient is experiencing.

Choice J reason: Monitoring lung sounds is essential for assessing the effectiveness of treatment and progression of pneumonia. Diminished lung sounds can indicate poor air movement due to the infection.

Choice K reason: Changes in the level of consciousness can indicate worsening hypoxia and should be monitored closely. A decrease in consciousness can be a sign of inadequate brain oxygenation.

Choice L reason: Oxygen saturation is a direct measure of the patient’s respiratory status and should be monitored to assess the effectiveness of oxygen therapy and overall progression.

Choice M reason: While heart rhythm should be monitored in all patients, it is not the most specific parameter for assessing the progression of pneumonia or hypoxia.

Choice N reason: Temperature should be monitored to assess for fever, which can indicate infection or inflammation. However, it is not as directly related to respiratory function as oxygen saturation and lung sounds are in the context of pneumonia.

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Correct Answer is C

Explanation

Choice A reason: Advising the client to maintain bedrest may not be practical or beneficial for the client's overall health and does not address the UAP's concern about safe transfer.

Choice B reason: While it is true that all clients deserve equal care, this statement does not provide a solution to the UAP's concern about safely assisting the client.

Choice C reason: Determining the client's level of mobility and need for assistance will help in creating a safe and effective plan for transferring the client to the bedside commode.

Choice D reason: Assigning another UAP may be necessary if the current UAP is unable to assist safely, but it is not the first step. The nurse should first assess the situation before making staffing changes.

A. Prepare for a cesarean delivery B. Administer calcium gluconate C. Obtain blood pressure D. Stop infusion of magnesium E. Increase IV fluids F. Administer oxygen G. Obtain serum magnesium level H. Make preparations to prevent cardiac arrest

Correct Answer is ["B","C","F","G","H"]

Explanation

Choice A reason: Preparing for a cesarean delivery is not indicated solely based on the information provided. The patient is at 36 weeks with moderate pre-eclampsia and there are no immediate signs of fetal distress or a need for emergency delivery based on the nurse’s notes.
Choice B reason: Administering calcium gluconate is appropriate if there are signs of magnesium sulfate toxicity, as it acts as an antidote. The patient’s decreased level of consciousness and absent DTRs may suggest magnesium toxicity, making this a correct intervention.
Choice C reason: Obtaining blood pressure is a standard and ongoing requirement for monitoring a pre-eclampsia patient, especially after noting a significant drop in blood pressure from 170/98 mm Hg to 118/78 mm Hg, which could indicate an overcorrection or other issues.
Choice D reason: Stopping the infusion of magnesium sulfate is not indicated at this time. While the patient’s decreased LOC and absent DTRs are concerning, magnesium sulfate is critical for preventing seizures in pre-eclampsia and should not be stopped without clear signs of overdose and physician consultation.
Choice E reason: Increasing IV fluids is not indicated and could be harmful. The patient already has pulmonary edema and increasing fluids could exacerbate this condition, especially in the context of pre-eclampsia where fluid management needs to be carefully balanced.
Choice F reason: Administering oxygen is correct as the patient’s oxygen saturation has dropped from 98% to 93%, and the goal is to maintain it above 96% as per the physician’s orders.
Choice G reason: Obtaining serum magnesium level is correct because it is necessary to monitor for signs of magnesium sulfate toxicity given the patient’s symptoms of decreased LOC and absent DTRs.
Choice H reason: Preparing to prevent respiratory or cardiac arrest is correct as the patient has signs that may suggest impending magnesium sulfate toxicity, which can lead to respiratory depression or cardiac arrest.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Patient Data Exhibits The nurse reviews the assessment findings along with the physician orders. Which immediate interventions would the nurse initiate? Select all that apply.

Correct Answer is ["B","C","F","G","H"]

Explanation

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