Patient Data
Place client on oxygen 2 10 4 liters and maintain oxygen saturation at or above, 959%.
Start the client on antibiotic therapy
STAT complete blood count (CBC), basic metabolic panel (BMP), and blood cultures
Stat ventilation/perfusion (V/Q) of chest
Send sputumn for culture & sensitivity
STAT 2 views chest x-ray
Correct Answer : B,C,E
B. Start the client on antibiotic therapy - Antibiotics are typically prescribed to treat bacterial pneumonia, which is a common cause of pneumonia.
C. STAT complete blood count (CBC), basic metabolic panel (BMP), and blood cultures - These tests help in assessing the severity of the infection, evaluating electrolyte balance, and identifying the causative organism respectively.
E. Send sputum for culture & sensitivity - This helps in identifying the specific organism causing the pneumonia and determining the most effective antibiotic for treatment.
A. At an oxygen saturation above 90%, the client does not necessarily require oxygen supplementation
D. A ventilation/ perfusion scan is needed in cases of suspected pulmonary embolism which is unlikely in this case.
F. Another chest X ray is not important as a recent one is present. No much changes is expected in the period of the few hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Postural drainage involves placing the client in various positions to help drain secretions from different lobes of the lungs. There are typically five standard positions: head-down, head-up, on the side with the affected lung uppermost, on the side with the affected lung lowermost, and lying prone.
A. Performing postural drainage immediately after meals is not recommended because it can increase the risk of vomiting or aspiration, especially in individuals with chronic obstructive pulmonary disease (COPD) who may already have compromised lung function.
C. In postural drainage, the client is typically instructed to breathe deeply and slowly to maximize the effectiveness of the technique.
D. While ABGs may be necessary for monitoring respiratory status in clients with COPD, they are not specifically required prior to performing postural drainage.
Correct Answer is C
Explanation
C. Type I hypersensitivity reactions, also known as immediate hypersensitivity reactions, involve the production of IgE antibodies in response to an allergen. In this case, the bee sting likely triggered an IgE-mediated immune response, leading to the release of inflammatory mediators such as histamine. The client's symptoms of body rash, shortness of breath, tachycardia, and hypotension are characteristic of anaphylaxis, which is a severe and potentially life-threatening manifestation of Type I hypersensitivity reactions.
A.. Type II hypersensitivity reactions occur when the immune system targets antigens on the body's own cells, leading to cell destruction or dysfunction.
B. Autoimmune responses involve the immune system mistakenly attacking the body's own tissues and organs, leading to inflammation and tissue damage.
D. Cell-mediated hypersensitivity reactions involve the activation of T cells and the release of cytokines, resulting in inflammation and tissue damage. Examples include delayed-type hypersensitivity reactions such as contact dermatitis or tuberculin skin testing reactions.
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