The nurse is providing care for a patient admitted for a lower respiratory infection. On admission, the patient's vital signs were blood pressure (BP) 140/80 mm Hg. apical pulse (AP) 112 beats/minute, respirations (R) 32 breaths/minute, and pain level of 8 on a scale of 0 to 10. After assisting the patient to bed and applying the prescribed oxygen, which finding helps the nurse evaluate the effectiveness of nursing care?
P 100 beats/minute
R 20 breaths/minute
BP 130/78 mm Hg
Pain level of 6/10
The Correct Answer is B
B. A decrease in the respiratory rate from 32 breaths/minute to 20 breaths/minute indicates improved respiratory status and effectiveness of nursing care. A lower respiratory rate suggests that the patient's breathing is becoming less labored, and oxygenation may be improving.
A. A lower heart rate may suggest a reduction in pain, improved oxygenation, or decreased stress on the cardiovascular system. However, other factors such as medications, rest, and hydration can also influence heart rate. Overall, a decrease in heart rate is a favorable finding.
C. A slight decrease in blood pressure from 140/80 mm Hg to 130/78 mm Hg may indicate a positive response to nursing care. However, blood pressure fluctuations can be influenced by various factors, including hydration status, medications, and underlying medical conditions.
D. Pain management is an essential aspect of nursing care, particularly for patients with lower respiratory infections who may experience discomfort due to coughing, chest congestion, and inflammation. However, pain levels can fluctuate over time and may require ongoing assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Diabetes can lead to damage of blood vessels throughout the body, both large and small. Complications can affect various organs and systems, including the heart, kidneys, eyes, and nerves. Damage to both large vessels (macrovascular complications) and tiny vessels (microvascular complications) contributes to the diverse range of complications associated with diabetes.
B. Both type 1 and type 2 diabetes increase the risk of long-term complications, but the specific risks and patterns of complications may differ between the two types. While individuals with type 1 diabetes may face challenges in achieving tight glycemic control due to the complete absence of endogenous insulin production, tight control can significantly reduce the risk of complications in both type 1 and type 2 diabetes.
C. Lower HbA1c levels indicate better overall glycemic control and are associated with reduced risk of long-term complications. However, achieving tight glycemic control should be balanced with the risk of hypoglycemia and individual patient factors.
D. Hypoglycemia can also lead to increased risk of cardiovascular events and mortality in individuals with diabetes. Therefore, it is important to balance glycemic control to minimize the risk of hypoglycemia while also reducing the risk of hyperglycemia-related complications.
Correct Answer is A
Explanation
A. Holding the breath for at least 10 seconds after inhaling the medication allows the medication to settle in the lungs and increases its effectiveness. This ensures maximum delivery of the drug to the respiratory tract.
B. The recommended time to wait between inhalations is typically around 1 to 2 minutes, not 10 minutes. Waiting too long between puffs may reduce the effectiveness of the medication and is not necessary.
C. There is no specific recommendation that the inhaler must be held with the non-dominant hand. The inhaler should be held in the hand that feels most comfortable and provides the best control, which is usually the dominant hand for most people.
D. The correct technique involves tilting the head slightly back to open the airway, making it easier for the medication to reach the lungs. Tilting the head forward could restrict the airflow and reduce the effectiveness of the inhalation.
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