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A patient with pneumonia has a fever of 101.4 F (38.6 C), a nonproductive cough, and an oxygen saturation of 88%. The patient complains of weakness, fatigue, and needs assistance to get out of bed. Which nursing diagnosis should the nurse assign as the highest priority?
- A. Hyperthermia related to infectious illness
- B. Impaired transfer ability related to weakness
- C. Ineffective airway clearance related to thick secretions
- D. Impaired gas exchange related to respiratory congestion
Correct Answer: D
Rationale: The correct answer is 'Impaired gas exchange related to respiratory congestion.' While all the nursing diagnoses are relevant to the patient's condition, the priority should be given to impaired gas exchange due to the patient's low oxygen saturation level of 88%. This indicates a significant risk of hypoxia for all body tissues unless the gas exchange is improved. Addressing impaired gas exchange is crucial to ensure adequate oxygenation and prevent further complications. Hyperthermia, impaired transfer ability, and ineffective airway clearance are important concerns but addressing gas exchange takes precedence in this scenario.
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A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
- A. Performing a chest x-ray via stretcher
- B. Obtaining blood cultures from two sites
- C. Administering Ciprofloxacin (Cipro) 400 mg IV
- D. Inserting an Acetaminophen (Tylenol) rectal suppository
Correct Answer: B
Rationale: In a patient with probable bacterial pneumonia and sepsis, the priority intervention is to obtain blood cultures from two sites before initiating antibiotic therapy. This is crucial to identify the causative organism and guide appropriate antibiotic treatment. Administering antibiotics without obtaining cultures first can interfere with accurate results. Performing a chest x-ray and administering acetaminophen can be done after obtaining blood cultures as they are important but not as urgent as identifying the causative organism in sepsis.
The nurse assesses a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important for the nurse to report to the healthcare provider?
- A. Respirations are 36 breaths/minute.
- B. Anterior-posterior chest ratio is 1:1.
- C. Lung expansion is decreased bilaterally.
- D. Hyperresonance to percussion is present.
Correct Answer: A
Rationale: The correct answer is 'Respirations are 36 breaths/minute.' An increased respiratory rate is a crucial sign of respiratory distress in patients with COPD, necessitating immediate interventions like oxygen therapy or medications. The other options are common chronic changes seen in COPD patients. Option B, the 'Anterior-posterior chest ratio is 1:1,' is related to the barrel chest commonly seen in COPD due to hyperinflation. Option C, 'Lung expansion is decreased bilaterally,' is expected in COPD due to air trapping. Option D, 'Hyperresonance to percussion is present,' is typical in COPD patients with increased lung volume and air trapping.
After 2 months of tuberculosis (TB) treatment with isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol, a patient continues to have positive sputum smears for acid-fast bacilli (AFB). Which action should the nurse take next?
- A. Teach about drug-resistant TB treatment
- B. Ask the patient whether medications have been taken as directed
- C. Schedule the patient for directly observed therapy three times weekly
- D. Discuss with the healthcare provider the need for the patient to use an injectable antibiotic
Correct Answer: B
Rationale: The first action should be to determine whether the patient has been compliant with drug therapy because negative sputum smears would be expected if the TB bacillus is susceptible to the medications and if the medications have been taken correctly. Assessment is the first step in the nursing process. Depending on whether the patient has been compliant or not, different medications or directly observed therapy may be indicated. The other options are interventions based on assumptions until an assessment has been completed. Teaching about drug-resistant TB treatment (Choice A) is premature without knowing the current medication compliance status. Scheduling directly observed therapy (Choice C) assumes non-compliance without confirming it first. Discussing the need for an injectable antibiotic (Choice D) is premature and not necessarily indicated without assessing the current medication adherence.
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
- A. A large air leak in the water-seal chamber
- B. 400 mL of blood in the collection chamber
- C. Complaint of pain with each deep inspiration
- D. Subcutaneous emphysema at the insertion site
Correct Answer: B
Rationale: The nurse should be most concerned if 400 mL of blood is observed in the collection chamber as it may indicate the patient is at risk of developing hypovolemic shock. A large air leak in the water-seal chamber is expected initially after chest tube placement for a pneumothorax. While pain with deep inspiration should be treated, it is not as urgent as the risk of continued hemorrhage. Subcutaneous emphysema is not uncommon in a patient with pneumothorax and is usually harmless. However, a large amount of blood in the collection chamber is a more critical finding that requires immediate attention to prevent potential complications.
The nurse develops a plan of care to prevent aspiration in a high-risk patient. Which nursing action will be most effective?
- A. Turn and reposition immobile patients at least every 2 hours.
- B. Place patients with altered consciousness in side-lying positions.
- C. Monitor for respiratory symptoms in immunosuppressed patients.
- D. Insert nasogastric tube for feedings in patients with swallowing problems.
Correct Answer: B
Rationale: To prevent aspiration in a high-risk patient, the most effective nursing action is to place patients with altered consciousness in side-lying positions. This position helps decrease the risk of aspiration as it prevents pooling of secretions and facilitates drainage. Turning and repositioning immobile patients every 2 hours is essential for preventing pressure ulcers and improving circulation but does not directly address the risk of aspiration. Monitoring respiratory symptoms in immunosuppressed patients is crucial to detect pneumonia early, but it does not directly prevent aspiration. Inserting a nasogastric tube for feedings in patients with swallowing problems may be necessary for nutritional support but does not address the risk of aspiration directly. Patients at high risk for aspiration include those with altered consciousness, difficulty swallowing, and those with nasogastric intubation, among others. Placing patients with altered consciousness in a side-lying position is a key intervention to reduce the risk of aspiration in this population. Other high-risk groups for aspiration include those who are seriously ill, have poor dentition, or are on acid-reducing medications.