The 79-year-old patient with bacterial pneumonia becomes increasingly restless and confused. Temperature is 100° F and pulse, blood pressure, and respirations are elevated since the last assessment 6 hours ago. The initial intervention by the nurse should be to:
administer an NSAID for discomfort
assess the patient's 02 saturation
check the MAR for an order for a mild sedative
take the patient off of oral fluids
The Correct Answer is B
A. Administer an NSAID for discomfort: While fever and discomfort may contribute to restlessness, NSAIDs do not address the most urgent concern, which is potential hypoxia. Treating symptoms without first assessing respiratory function may delay appropriate intervention.
B. Assess the patient's O₂ saturation: Increasing restlessness and confusion in a pneumonia patient can be early signs of hypoxia, especially in older adults. Oxygen saturation should be evaluated immediately to determine if the patient needs supplemental oxygen or further respiratory support.
C. Check the MAR for an order for a mild sedative: Sedatives may worsen confusion and can depress respiratory drive, particularly in hypoxic patients. Administering a sedative without first ruling out hypoxia may pose significant risk.
D. Take the patient off of oral fluids: Unless there are clear signs of aspiration or decreased level of consciousness, discontinuing oral fluids is not an appropriate first step. Hydration is important in pneumonia to help thin secretions and support recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Determining the last time the patient was suctioned:The timing of previous suctioning is not a reliable indicator of current need. Suctioning is a clinical decision based on assessment, not a fixed schedule or time interval.
B. Auscultating the breath sounds:Listening to lung sounds helps detect the presence of secretions, such as crackles or rhonchi, indicating airway obstruction. This is the most direct and effective method to assess the need for suctioning in a tracheostomized patient.
C. Monitoring the rate of respirations:An increased respiratory rate can suggest respiratory distress but is non-specific and may result from various causes, including anxiety, fever, or pain. It does not definitively indicate the presence of secretions.
D. Examining the character of the sputum:Sputum characteristics provide information about infection or hydration status, but unless secretions are visibly present or obstructing the airway, they don’t confirm the immediate need for suctioning.
Correct Answer is D
Explanation
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.
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