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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
To convert 12: am to military time, for any time between 12: am and 12: am, the 12 is replaced with 00. Therefore, 12: am becomes 0018 in military time.
Choice B rationale
2418 is not a valid representation of time in either standard or military format. Military time ranges from 0000 to 2359.
Choice C rationale
1218 in military time represents 12: pm in standard time, not 12: am. In the afternoon and evening, 12 is added to the standard hour to convert to military time (e.g., 1 pm is 1300).
Choice D rationale
0118 in military time represents 1: am in standard time. The hour remains the same for times between 1: am and 9: am, with a leading zero added to the hour. .
Correct Answer is A
Explanation
Choice A rationale
Nurses have a professional and legal obligation to maintain patient confidentiality. Accessing medical records should be limited to patients for whom the nurse is currently responsible for providing care. This ensures that patient information is viewed only when necessary for care delivery, upholding privacy and security standards.
Choice B rationale
Allowing nurses unrestricted access to any client's medical records within the healthcare facility, even without sharing, is a breach of privacy principles. Access should be role-based and justified by the need to provide care to that specific patient. Broad access increases the risk of unauthorized viewing of sensitive information.
Choice C rationale
Sharing a client's medical record information is restricted by privacy laws like HIPAA. Information can generally only be shared with individuals the patient has explicitly consented to, not automatically with immediate family members unless the patient has provided authorization. There are specific legal guidelines regarding disclosure of patient health information.
Choice D rationale
Sharing a client's medical information with other clients, even those with similar diagnoses, is a violation of patient confidentiality. Each patient's medical record is private, and discussing one patient's case with another, without explicit consent, is unethical and potentially illegal. .
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