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 A
Explanation
A. Atenolol is a beta-blocker, which can lower heart rate and blood pressure. A heart rate of 52 and a blood pressure of 90/56 are both abnormally low. The nurse should hold the medication and contact the provider, as this could indicate bradycardia or hypotension, both of which can be dangerous.
B. Recent intake of sildenafil. Sildenafil (Viagra) can interact with beta-blockers and cause a further drop in blood pressure. However, the priority is addressing the abnormal heart rate and blood pressure from option A before focusing on this interaction. The nurse should still monitor the patient closely for any significant changes in blood pressure, but the primary concern is not the interaction here.
C. Positional vertigo and wheezing. While wheezing could be a concern (as beta-blockers can exacerbate bronchospasm in patients with asthma or chronic lung conditions), positional vertigo may be more related to hypotension from the atenolol. Nonetheless, the priority here remains the low heart rate and blood pressure in option A, which is a more immediate concern.
D. Restlessness and mild confusion. These could be side effects or signs of an adverse reaction to atenolol, but they are less urgent compared to the low heart rate and blood pressure found in option A. The nurse should still assess the patient's mental status but prioritize contacting the provider for the more critical findings.
Correct Answer is B
Explanation
A. Have you tried videos or flash cards? People learn in different ways.: While videos or flashcards might be helpful tools for some, this response doesn't address the primary concern, which is consistency in the approach for memory recall. Reinforcing one method consistently is crucial for individuals with traumatic brain injuries (TBI) to help improve memory retention.
B. It is important to reinforce one consistent method due to the injury.: This is the best response. Individuals with brain injuries, especially those affecting memory, benefit from consistent, structured methods of learning and remembering. Changing the approach frequently can confuse the patient and hinder their progress. Reinforcing one method consistently will provide the brain with a routine to help it form connections and improve memory.
C. Does he have a favorite type of music? Background music helps with memory.: While music can sometimes be used in memory therapies, the suggestion of using music as background for memory enhancement is not a reliable or consistent approach. It doesn't address the need for a structured, consistent method that would be most beneficial in this case.
D. Maybe he is depressed due to the injury, Depression alters concentration.: While depression can affect cognitive functions such as concentration and memory, there is no direct indication in the partner’s statement that depression is the primary concern here. Focusing on consistent memory strategies is more appropriate as a first step.
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