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. Sucralfate works by forming a protective barrier over the ulcer site. It adheres to the ulcer, shielding it from the harmful effects of gastric acid, pepsin, and bile salts. This protection allows the ulcer to heal by preventing further irritation and damage.
B. Medications that prevent gastric acid secretion are typically proton pump inhibitors (PPIs) or H2 receptor antagonists. Sucralfate does not reduce or inhibit the production of gastric acid; instead, it protects the ulcer from the acid already present.
C. Antacids are the type of medication that neutralize gastric acid. Sucralfate does not neutralize acid; it acts locally at the ulcer site to create a protective coating.
D. Antibiotics are used to kill Helicobacter pylori, the bacteria often responsible for causing peptic ulcers. Sucralfate does not have antibacterial properties and does not target or eliminate bacteria.
Correct Answer is A
Explanation
A. Asthma is a chronic respiratory condition characterized by inflammation and hyperresponsiveness of the airways. This inflammation leads to bronchoconstriction, causing symptoms like wheezing, shortness of breath, chest tightness, and coughing. This description accurately captures the primary pathological features of asthma.
B. Fluid in the lungs, also known as pulmonary edema, is not a characteristic of asthma. Pulmonary edema is usually associated with conditions such as heart failure or acute respiratory distress syndrome (ARDS), not asthma.
C. Airway stretching and nonfunctionality are not characteristics of asthma. Conditions like bronchiectasis involve permanent dilation and damage to the airways, leading to chronic infections and impaired clearance of mucus, but this is different from asthma.
D. Asthma is not primarily caused by an infection, although infections can trigger asthma exacerbations. The primary issue in asthma is chronic inflammation and hyperresponsiveness of the airways, which are not caused by a low-grade infection but by a combination of genetic and environmental factors.
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