The patient with pneumonia is being treated with intravenous antibiotics. The nurse evaluates that the therapy has been effective by which data?
Respiratory rate 26, irregular: Pt reports no shortness of breath or chills
Temp-99F (37.2 Or Lungs clear bilaterally: Pulse ox 98% on 2 liters oxygen; productive cough: clear to yellow sputum
Pt reports fatigue: Resp rate 28 on 2 liters oxygen: audible expiratory wheezes:
Cough: white sputum: Temp 99F (37.2 C); Pulse ox 96%
The Correct Answer is B
A. Respiratory rate 26, irregular: Pt reports no shortness of breath or chills: An irregular respiratory rate may indicate some underlying issues. Although the patient reports no shortness of breath or chills, an irregular respiratory rate could signal a cardiac issue or a lingering effect of the infection. It’s not sufficient to confirm the effectiveness of antibiotic therapy.
B. Temp-99F (37.2°C); Lungs clear bilaterally; Pulse ox 98% on 2 liters oxygen; productive cough: clear to yellow sputum: This indicates improvement in the patient’s condition:
A temperature of 99°F is a mild, controlled fever, which is common in the recovery phase but suggests a reduction from higher fever associated with infection.
Clear lungs bilaterally are a good sign, indicating that there is no longer significant consolidation or inflammation in the lungs.
Pulse oximetry of 98% on 2 liters of oxygen is a positive sign that the oxygenation is improving.
Productive cough with yellow sputum indicates that the body is still clearing the infection, but it is a typical sign of recovery as the patient produces sputum.
C. Pt reports fatigue: Resp rate 28 on 2 liters oxygen: audible expiratory wheezes: This is concerning. The patient is still experiencing fatigue and audible wheezes, which may indicate unresolved inflammation or bronchoconstriction. The respiratory rate of 28, while slightly elevated, also suggests ongoing respiratory stress. This could indicate that the infection is not fully controlled.
D. Cough: white sputum: Temp 99F (37.2°C); Pulse ox 96%: This is somewhat positive, but it lacks the detail of clear lungs or other more definitive signs of improvement. The white sputum could suggest that the infection is resolving, but there is still some degree of infection or inflammation. Pulse ox at 96% is acceptable, but the lack of clear lungs bilaterally makes it less ideal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Atorvastatin at bedtime to reduce my cholesterol levels.: is a statin used to lower cholesterol levels and reduce the risk of further cardiovascular events. It is commonly recommended to take statins in the evening because cholesterol synthesis occurs mostly at night. The client is following proper instructions here.
B. Metoprolol to decrease my heart's need for oxygen.: Metoprolol is a beta-blocker that reduces the heart's demand for oxygen by lowering the heart rate, blood pressure, and the force of contraction. This helps in reducing the risk of further complications after a myocardial infarction (MI).
C. Sublingual nitroglycerin each day to prevent chest pain.: This indicates the need for further education. Sublingual nitroglycerin is typically used as needed for acute chest pain or angina and should not be taken regularly each day for prevention. For long-term prevention, other medications like beta-blockers or calcium channel blockers are usually prescribed, not sublingual nitroglycerin. Taking nitroglycerin every day without chest pain could cause unnecessary side effects, such as hypotension or tolerance to the medication.
D. Clopidogrel to prevent clots from forming.: Clopidogrel is an antiplatelet medication that helps to prevent blood clots from forming by inhibiting platelet aggregation. It is often prescribed following a myocardial infarction to reduce the risk of further clot formation and to improve cardiovascular outcomes.
Correct Answer is A
Explanation
A. A change in the pattern of shortness of breath can be a sign of worsening respiratory or cardiovascular status and may indicate a serious condition such as pulmonary embolism, heart failure, or a pneumothorax. This requires immediate assessment and further investigation to determine the cause.
B. While flank pain (7/10) after receiving oral analgesic could be concerning, the fact that the pain is still significant 15 minutes after medication administration suggests that the pain may not yet be well-controlled. However, this is not as immediately urgent as a change in breathing pattern, so this patient should be assessed after the one with respiratory concerns.
C. Serosanguinous drainage from a JP drain on postoperative day 3 is not uncommon, and this typically does not require immediate intervention unless the drainage increases significantly or becomes more sanguine. This patient should be assessed after the one with a change in shortness of breath.
D. Bilateral wheezes after walking 40 feet, with a pulse oximetry of 96% on room air, is concerning but not as urgent as a change in shortness of breath. The pulse oximetry is within the normal range, and wheezing could be related to mild exertion or an underlying chronic condition (like asthma), but the patient’s condition doesn’t seem to be immediately life-threatening. This patient should be assessed after the patient with shortness of breath.
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