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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Correct Answer is B

Explanation

B. Beta cells are the pancreatic cells responsible for secreting insulin. Insulin acts to lower blood sugar levels by facilitating the uptake of glucose into cells for energy or storage. In individuals with diabetes mellitus, dysfunction of beta cells can lead to inadequate insulin secretion, resulting in high blood sugar levels.
A. Alpha cells are another type of cell in the pancreas, but they secrete glucagon, not insulin. Glucagon has the opposite effect of insulin, increasing blood sugar levels by stimulating the breakdown of glycogen in the liver.
C. Acinar cells are exocrine cells found in the pancreas that secrete digestive enzymes into the pancreatic ducts. These enzymes aid in the digestion of food in the small intestine. Acinar cells are not involved in the production of insulin.
D. Plasma cells are a type of white blood cell that produces antibodies as part of the immune response. They are not involved in the production of insulin.

A. Identifying age-related changes B. Monitoring BG level C. Establishing the presence of an illness D. Improving hydration status

Correct Answer is D

Explanation

D. The priority focus in the acute management of hyperosmolar hyperglycemia is improving hydration status. Patients with HHS are severely dehydrated due to the osmotic diuresis caused by extremely high blood glucose levels. Rapid rehydration is critical to prevent shock, improve organ perfusion, and reduce blood glucose levels.
A. It's important to consider age-related changes in any patient but this is not the immediate priority in the acute management of hyperosmolar hyperglycemia. The primary concern is addressing the acute, life-threatening aspects of the condition.
B. Monitoring blood glucose levels is critical in managing hyperosmolar hyperglycemia. However, while it is essential to track the BG levels to guide insulin therapy and assess the response to treatment, it is not the immediate priority in terms of interventions needed to stabilize the patient initially.

C. Determining the underlying cause of hyperosmolar hyperglycemia, such as an infection or other illness, is important for comprehensive treatment. However, it is a secondary priority to stabilizing the patient’s current acute condition.

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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

What type of cells secrete insulin?

Correct Answer is B

Explanation

A patient is admitted to the hospital with hyperosmolar hyperglycemia. The patient has a BG value of 987 mg/dL. Which is the priority focus while providing care?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse identify as a risk factor for this condition?

The patient with emphysema comes to the emergency department with difficulty breathing. What finding should the nurse anticipate during data collection? Select all that apply

A nurse is collecting data from a client who has gastroesophageal reflux disease (GERD) and reports having heartburn every night. Which of the following actions should the nurse identify as a contributing factor to the client's heartburn?

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?

A newly diagnosed patient asks the nurse to explain asthma. Which of the following explanations by the nurse is correct?

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?

A patient is admitted to a respiratory unit with a diagnosis of bacterial pneumonia. Findings include a fever and a weak, congested-sounding cough with moist crackles throughout the lung fields. How should the nurse prioritize care?

A patient with newly diagnosed diabetes asks the nurse what to take for low blood sugar. Which of the following would be most appropriate for the nurse to suggest?