The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider?
The patient has a cough that is productive of blood-tinged sputum.
The patient's temperature is 101.5 F after 2 days of IV antibiotic therapy.
The patient has scattered crackles throughout the posterior lung bases.
The patient's SpO2 has dropped to 90%, although the O2 flow rate has been increased.
The Correct Answer is D
Rationale:
A. Blood-tinged sputum can occur with irritation of the airways or forceful coughing. While it warrants monitoring, it is not immediately life-threatening in the context of pneumonia unless it becomes massive hemoptysis.
B. A mild fever after 2 days of antibiotics may indicate that the infection is still responding or that the therapeutic effect has not fully taken place. While it should be reported, it is not as urgent as a significant oxygenation problem.
C. Crackles are a common finding in pneumonia and reflect fluid in the alveoli. This is expected and not an urgent change requiring immediate provider notification.
D. A drop in oxygen saturation despite increased oxygen support indicates worsening hypoxemia, which is an acute and potentially life-threatening deterioration. This could signal progression of pneumonia, development of acute respiratory distress, or another complication such as a pulmonary embolism. Prompt communication with the healthcare provider is essential to prevent respiratory failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Flat positioning increases the risk of aspiration, which can lead to ventilator-associated pneumonia (VAP). Evidence-based guidelines recommend elevating the head of the bed to 30–45 degrees to reduce aspiration risk.
B. While turning the patient helps prevent pressure injuries and promotes circulation, there is no strong evidence that turning alone significantly reduces the risk of VAP. Frequent repositioning is beneficial but not the primary preventive measure for pneumonia.
C. Oral hygiene is a key intervention to prevent ventilator-associated pneumonia. The endotracheal tube bypasses normal airway defenses, allowing colonization of oral bacteria that can be aspirated into the lungs. Brushing the teeth and oral care with suctioning removes dental plaque and secretions, reducing bacterial load and the risk of VAP. Best practice is to perform oral care every 12 hours or more frequently.
D. Humidification is essential for airway comfort and secretion management, but it does not prevent bacterial colonization or VAP. While necessary for patient care, it is not a primary preventive measure against ventilator-associated pneumonia.
Correct Answer is D
Explanation
Rationale:
A. Potassium replacement may be required later during insulin therapy, but Diamox (acetazolamide) is not indicated. Diamox is used for metabolic alkalosis or other unrelated conditions, not for diabetic ketoacidosis.
B. The client is hyperventilating to compensate for metabolic acidosis (Kussmaul respirations). Suppressing respirations would worsen acidosis and increase the risk of respiratory failure
C. These interventions are appropriate for pulmonary infections or fluid overload, not metabolic acidosis due to DKA.
D. The priority interventions for diabetic ketoacidosis include intravenous fluids to correct dehydration and improve perfusion, insulin therapy to reduce hyperglycemia and stop ketone production, and oxygen therapy if hypoxia is present. Electrolytes and cardiac monitoring are also important, but fluids, insulin, and oxygen are the immediate life-saving measures.
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