The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

Heart rate of 104 bpm

Tympanic temperature of 102.6°F (39.2°C)

Blood pressure of 158/90 mmHg

Respiratory rate of 24 breaths/min

Answer and Explanation

The Correct Answer is B

Choice A reason: A heart rate of 104 bpm can be expected in a client with pneumonia and after suctioning. Tachycardia (elevated heart rate) can occur as a response to infection, stress, or the suctioning procedure itself. While it should be monitored, it is not the most critical finding.

Choice B reason: A tympanic temperature of 102.6°F (39.2°C) is unexpected and indicates a significant fever, which may suggest a worsening infection or sepsis. This finding requires immediate attention as it could indicate that the current treatment for pneumonia is not effective, and the client's condition may be deteriorating.

Choice C reason: A blood pressure of 158/90 mmHg, though elevated, may be less critical in the context of this client's condition. Hypertension can occur due to various factors, including stress and illness, and should be monitored but is not the most urgent priority compared to a high fever.

Choice D reason: A respiratory rate of 24 breaths/min is slightly elevated but can be expected in a client with pneumonia and after suctioning. This rate indicates mild tachypnea, which should be monitored but is not as immediately concerning as a high fever.

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Correct Answer is C

Explanation

Choice A reason: Intermittent mild headaches can be a side effect of estrogen therapy, but they are generally not life-threatening. While they should be monitored and managed, they do not constitute an immediate priority compared to more severe symptoms.

Choice B reason: Erectile dysfunction is a common side effect of estrogen therapy in transgender females. Although it can affect quality of life, it is not an urgent medical concern and does not require immediate intervention.

Choice C reason: Dyspnea (difficulty breathing) and chest pain are potentially serious symptoms that could indicate cardiovascular issues, including pulmonary embolism, which is a known risk associated with estrogen therapy. These symptoms require immediate attention and intervention to rule out life-threatening conditions.

Choice D reason: Elevated liver function tests can occur with estrogen therapy and should be monitored over time. However, while they indicate a need for further investigation and possible adjustment of therapy, they are not as immediately critical as symptoms of dyspnea and chest pain.

A. Taking vital signs and pulse oximetry readings every hour. B. Checking the ventilator setting to make sure they are set as prescribed. C. Observing if the client's endotracheal tube needs suctioning every 2 hours. D. Assessing the client's respiratory status every 4 hours.

Correct Answer is A

Explanation

Choice A reason: Taking vital signs and pulse oximetry readings is a task that can be safely delegated to an experienced unlicensed assistive personnel (UAP). This task involves routine monitoring and does not require clinical judgment or decision-making, making it appropriate for UAPs to handle.

Choice B reason: Checking the ventilator settings requires specific knowledge about ventilator operation and adjustments. This task should be performed by a licensed nurse or respiratory therapist to ensure the settings are correct and appropriate for the client's condition.

Choice C reason: Observing if the client's endotracheal tube needs suctioning requires clinical assessment and judgment to determine the necessity and frequency of suctioning. This task should be performed by a licensed nurse who can evaluate the client's respiratory status and make appropriate decisions.

Choice D reason: Assessing the client's respiratory status involves comprehensive evaluation of the client's breathing, lung sounds, and overall respiratory function. This task requires clinical judgment and should be performed by a licensed nurse who can interpret the findings and respond appropriately.

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The nurse is assessing a mechanically ventilated client with pneumonia after providing deep oral suctioning to the client. Which assessment finding would be unexpected and be a priority for the nurse to address?

Nursing Test Bank

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