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. Type 1 diabetes is an autoimmune condition where the body's immune system attacks and destroys the insulin-producing beta cells in the pancreas. As a result, the pancreas produces little to no insulin, which is essential for regulating blood glucose levels.
B. Type 1 diabetes is not reversible. It is a lifelong condition that requires ongoing management with insulin therapy. While diet, exercise, and weight management are important for overall health and can help manage blood glucose levels, they cannot reverse type 1 diabetes.
C. This description is characteristic of type 2 diabetes, not type 1. In type 2 diabetes, the body’s cells become resistant to the effects of insulin, and the pancreas may not produce enough insulin. In type 1 diabetes, the problem is the lack of insulin production due to autoimmune destruction of the pancreatic beta cells.
D. Insulin is not released into the gastrointestinal tract. Insulin is a hormone that is released into the bloodstream by the pancreas. Its primary role is to help regulate blood glucose levels by facilitating the uptake of glucose into the body's cells for energy.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"A"}}
Explanation
Hypoglycemia
Tremor is a common symptom of hypoglycemia, as low blood sugar levels can lead to shaky hands and trembling.
Seizures can occur in severe cases of hypoglycemia when the brain is deprived of glucose, leading to abnormal electrical activity and convulsions.
Sweating, particularly cold and clammy skin, is a common symptom of hypoglycemia as the body responds to low blood sugar levels.
Hunger or sudden feelings of extreme hunger are common symptoms of hypoglycemia as the body seeks additional fuel to raise blood sugar levels.
Hyperglycemia
Lethargy, or extreme fatigue and drowsiness, is more commonly associated with hyperglycemia, as elevated blood sugar levels can affect energy levels and lead to feelings of sluggishness.
Polydipsia is a classic symptom of hyperglycemia, as high blood sugar levels can cause dehydration and trigger the body's thirst response.
Abdominal pain is more commonly associated with hyperglycemia, particularly in conditions like diabetic ketoacidosis (DKA), where abdominal discomfort can be a sign of metabolic disturbances.
Polyuria is a classic symptom of hyperglycemia, as high blood sugar levels can lead to increased urine production as the kidneys work to remove excess glucose from the bloodstream.
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