Which nursing diagnosis is the highest priority for a patient with pneumonia?
Impaired gas exchange related to alveolar inflammation and infection.
Pruritus related to side effects of prescribed medications.
Knowledge deficit related to pneumonia risk factors.
Activity intolerance related to fatigue and shortness of breath.
The Correct Answer is A
Choice A rationale
Impaired gas exchange directly affects the patient's oxygenation and carbon dioxide elimination, which are fundamental physiological needs. Alveolar inflammation and infection in pneumonia disrupt the normal diffusion of gases in the lungs, potentially leading to hypoxemia and hypercapnia, posing an immediate threat to life if not addressed promptly. Normal partial pressure of oxygen (PaO₂) is 80-100 mmHg, and normal partial pressure of carbon dioxide (PaCO₂) is 35-45 mmHg.
Choice B rationale
Pruritus, or itching, while uncomfortable, is a symptom related to medication side effects and does not directly compromise vital physiological functions like gas exchange. Addressing the underlying cause and providing symptomatic relief are important but are a lower priority than ensuring adequate oxygenation.
Choice C rationale
Knowledge deficit regarding risk factors for pneumonia is important for long-term health management and prevention of future episodes. However, in the acute phase of pneumonia, the immediate physiological compromise of impaired gas exchange takes precedence over addressing knowledge gaps.
Choice D rationale
Activity intolerance due to fatigue and shortness of breath is a consequence of the physiological changes associated with pneumonia, primarily the impaired gas exchange. While it affects the patient's quality of life, it is a manifestation of the primary problem rather than the most immediate threat to physiological stability.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
"Seems lethargic" is subjective and lacks specific, measurable data. Lethargy can manifest differently in patients, and this statement doesn't provide objective evidence to support the observation. Accurate documentation requires specific descriptions of observed behavior.
Choice B rationale
"The patient was incontinent" is more direct but lacks crucial details such as the type of incontinence (urinary or fecal), the amount, and any associated factors. Comprehensive documentation would include these specifics for a clear understanding of the event.
Choice C rationale
"The patient ate 25% of a hearty meal" is relatively objective and quantifiable, providing a specific measure of the patient's intake. However, "hearty" is still somewhat subjective. Specifying the type and estimated size of the meal would enhance clarity.
Choice D rationale
"The patient voided in the urinal" is a clear, objective statement of an observable action. It specifies the method of voiding and provides a concrete piece of information about the patient's urinary function. This type of documentation is precise and unambiguous.
Correct Answer is A
Explanation
Choice A rationale
AC and HS is a common abbreviation in medical orders that stands for "ante cibum" (before meals) and "hora somni" (at bedtime). Therefore, "ambulate patient four times a day AC & HS" means the patient should ambulate before breakfast, before lunch, before dinner, and at bedtime.
Choice B rationale
NG is an abbreviation for nasogastric, which refers to a tube inserted through the nose into the stomach and is not related to ambulation orders.
Choice C rationale
DNR stands for "do not resuscitate," which is a medical order regarding end-of-life care and is not related to ambulation.
Choice D rationale
STAT is an abbreviation meaning "immediately" and is typically used for urgent medications or treatments, not for routine ambulation orders.
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