Which patient does the LPN/LVN identify at high risk for hospital-acquired pneumonia?

A 35-year-old patient using the incentive spirometer following abdominal surgery

A 55-year-old patient who is eating in the chair following a rhinoplasty

A 40-year-old patient who refuses to cough and deep breath following a splenectomy

A24-year-old patient ambulating in the hall following an appendectomy

Answer and Explanation

The Correct Answer is C

C. This patient is at high risk for hospital-acquired pneumonia. After a splenectomy (removal of the spleen), patients may experience pain and discomfort, which can make them reluctant to perform necessary activities like coughing and deep breathing. These activities are crucial for preventing lung complications such as atelectasis and pneumonia.
A. This patient is actively using an incentive spirometer, which is a device that encourages deep breathing and helps keep the lungs clear. This practice significantly reduces the risk of developing pneumonia by preventing atelectasis (collapse of part of the lung) and promoting lung expansion.

B. This patient is out of bed and eating, which indicates they are relatively mobile and maintaining normal respiratory function. Rhinoplasty, a surgical procedure on the nose, generally does not impair lung function or significantly increase the risk of pneumonia. Being active and upright further reduces the risk of HAP.
D. This patient is actively ambulating, which is highly beneficial for lung function and overall recovery. Walking and moving around helps to prevent respiratory complications, including pneumonia, by promoting lung expansion and circulation.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"A"}}

Explanation

Hypoglycemia

Tremor is a common symptom of hypoglycemia, as low blood sugar levels can lead to shaky hands and trembling.

Seizures can occur in severe cases of hypoglycemia when the brain is deprived of glucose, leading to abnormal electrical activity and convulsions.

Sweating, particularly cold and clammy skin, is a common symptom of hypoglycemia as the body responds to low blood sugar levels.

Hunger or sudden feelings of extreme hunger are common symptoms of hypoglycemia as the body seeks additional fuel to raise blood sugar levels.

Hyperglycemia

Lethargy, or extreme fatigue and drowsiness, is more commonly associated with hyperglycemia, as elevated blood sugar levels can affect energy levels and lead to feelings of sluggishness.

Polydipsia is a classic symptom of hyperglycemia, as high blood sugar levels can cause dehydration and trigger the body's thirst response.

Abdominal pain is more commonly associated with hyperglycemia, particularly in conditions like diabetic ketoacidosis (DKA), where abdominal discomfort can be a sign of metabolic disturbances.

Polyuria is a classic symptom of hyperglycemia, as high blood sugar levels can lead to increased urine production as the kidneys work to remove excess glucose from the bloodstream.

A. Most complications involve either the large or tiny vessels of the body. B. Type 1 diabetics are at greatest risk for complications even with tight control. C. Patients with HbA1c levels below 6.9% are less likely to experience complications. D. Chronic hypoglycemia causes a variety of serious complications.

Correct Answer is A

Explanation

A. Diabetes can lead to damage of blood vessels throughout the body, both large and small. Complications can affect various organs and systems, including the heart, kidneys, eyes, and nerves. Damage to both large vessels (macrovascular complications) and tiny vessels (microvascular complications) contributes to the diverse range of complications associated with diabetes.
B. Both type 1 and type 2 diabetes increase the risk of long-term complications, but the specific risks and patterns of complications may differ between the two types. While individuals with type 1 diabetes may face challenges in achieving tight glycemic control due to the complete absence of endogenous insulin production, tight control can significantly reduce the risk of complications in both type 1 and type 2 diabetes.
C. Lower HbA1c levels indicate better overall glycemic control and are associated with reduced risk of long-term complications. However, achieving tight glycemic control should be balanced with the risk of hypoglycemia and individual patient factors.
D. Hypoglycemia can also lead to increased risk of cardiovascular events and mortality in individuals with diabetes. Therefore, it is important to balance glycemic control to minimize the risk of hypoglycemia while also reducing the risk of hyperglycemia-related complications.

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Which patient does the LPN/LVN identify at high risk for hospital-acquired pneumonia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge education about signs and symptoms of hypoglycemia and hyperglycemia. For each sign/symptom, indicate whether it is manifestation of hypoglycemia or hyperglycemia. Select one option in each row.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"A"}}

Explanation

The nurse is preparing to teach about the long-term complications for patients diagnosed with diabetes. Which finding is accurate?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease (GERD) about minimizing the effects of reflux during sleep. Which of the following client statements indicates an understanding of the teaching?

Your client has told you that they have been experiencing intermittent upper abdominal pain about 3 hours after eating and at times will even be awaken in the middle of the night by this pain. You suspect that your client may have which type of peptic ulcer?

A nurse is collecting data from a client who is having an acute asthma exacerbation. When auscultating the client's chest, the nurse should expect to hear which of the following sounds?

Management of asthma involves avoidance of triggers. Which environmental triggers will the nurse suggest the patient eliminate? Select all that apply. (Select All that Apply.)

A nurse is reinforcing discharge teaching with a client following an episode of status asthmaticus. The client has a prescription for two inhalations from an albuterol metered-dose inhaler. Which of the following statements by the client indicates an understanding of the teaching?

The nurse is assisting with nutrition teaching for a patient who voices concern over adjusting to a diabetic diet. Which response by the nurse about medical nutrition therapy is correct?