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.

Answer and Explanation

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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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. .

A. The family of the client in room 107. B. The client in room 105 had a bath. C. The client in room 108 received a new pain medication. D. The dietary preferences of the client in room 109.

Correct Answer is C

Explanation

Choice A rationale

Information about the family of a client in a different room (room 107) is not directly relevant to the change-of-shift report for the client in room 108. The report should focus on information pertinent to the care of the assigned client.

Choice B rationale

While the fact that a client in room 105 had a bath might be included in their specific report, it is not essential information to communicate during the change-of-shift report for the client in room 108 who has a new pain medication.

Choice C rationale

The administration of a new pain medication to the client in room 108 is crucial information for the oncoming nurse. It is essential to communicate the name of the medication, the time it was given, the dosage, the route of administration, and the client's response to the medication to ensure continuity of pain management.

Choice D rationale

The dietary preferences of a client in a different room (room 109) are not relevant to the change-of-shift report for the client in room 108. Dietary information is specific to each client and should be communicated within their individual report if pertinent to their current care.

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Which nursing diagnosis is the highest priority for a patient with pneumonia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Convert 12:18 am to military time:

Correct Answer is A

Explanation

The client in room 108 has been prescribed new pain medication.A nurse is providing change-of-shift report to the oncoming nurse.Which of the following information should the nurse include in the report?

Correct Answer is C

Explanation

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