Nokea
The 79-year-old patient with bacterial pneumonia becomes increasingly restless, confused,
and agitated. The patient’s temperature is 100° F, and his pulse, blood pressure, and
respirations are elevated since the last assessment 6 hours ago. What action should the nurse
take first?
- A. Auscultate the patient's lungs.
- B. Assess the patient's oxygen saturation.
- C. Administer the mild sedative as ordered.
- D. Administer an ordered analgesic for discomfort.
Correct Answer: B
Rationale: The correct answer is B: Assess the patient's oxygen saturation first. In a patient with bacterial pneumonia showing signs of restlessness, confusion, and agitation along with elevated vital signs, the priority is to assess oxygen saturation to rule out hypoxemia. Hypoxemia can lead to cognitive changes and increased agitation in older adults. Administering a sedative (choice C) or an analgesic (choice D) without addressing the underlying hypoxemia can worsen the patient's condition. Auscultating the lungs (choice A) is important but should come after assessing oxygen saturation to prioritize immediate interventions.
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The patient has just had an MRI ordered because a routine chest x-ray showed suspicious areas in the right lung. The physician suspects bronchogenic carcinoma. An MRI would most likely be ordered to assess for what in this patient?
- A. Alveolar dysfunction
- B. Forced vital capacity
- C. Tidal volume
- D. Chest wall invasion
Correct Answer: D
Rationale: The correct answer is D: Chest wall invasion. An MRI would be ordered to assess for any potential invasion of the chest wall by the suspected bronchogenic carcinoma. MRI provides detailed imaging of soft tissues and can help determine the extent of tumor invasion beyond the lungs.
Explanation:
A: Alveolar dysfunction - Alveolar dysfunction is typically assessed using pulmonary function tests or imaging techniques like CT scans, not MRI.
B: Forced vital capacity - Forced vital capacity is a measure of lung function and is not typically assessed using MRI.
C: Tidal volume - Tidal volume is a measure of the volume of air moved in and out of the lungs during normal breathing and is not assessed using MRI in this context.
An older adult is brought to the emergency department by a family member who reports a moderate change in mental status and mild cough. The client is afebrile. The primary health care provider orders a chest x-ray. The family member questions why this is needed since the symptoms seem so vague. What response by the nurse is best?
- A. Chest x-rays are always ordered when we suspect pneumonia.
- B. Older people often have vague symptoms, so an x-ray is essential.
- C. The x-ray can be done and read before laboratory work is reported.
- D. We are testing for any possible source of infection in the client.
Correct Answer: B
Rationale: The correct answer is B because older adults often present with atypical or vague symptoms when they have an underlying infection, including pneumonia. It is crucial to assess for pneumonia in older adults promptly because they may not exhibit classic signs like fever. An x-ray is essential to confirm or rule out pneumonia as it allows for visualization of lung abnormalities.
Choice A is incorrect because not all older adults with vague symptoms automatically have pneumonia, and ordering a chest x-ray is based on clinical judgment. Choice C is incorrect as the timing of the x-ray in relation to laboratory work is not the primary reason for ordering it. Choice D is incorrect because the x-ray is specifically to assess for pneumonia, not for general infection sources.
In addition to heart rate, blood pressure, respiratory rate, and temperature, the nurse needs to assess a patient's arterial oxygen saturation (SaO2). What procedure will best accomplish this?
- A. Incentive spirometry
- B. Arterial blood gas (ABG) measurement
- C. Peak flow measurement
- D. Pulse oximetry
Correct Answer: D
Rationale: Step 1: Pulse oximetry is a non-invasive method of measuring SaO2 by using a sensor attached to a patient's fingertip, earlobe, or toe.
Step 2: It provides immediate and continuous monitoring of oxygen saturation levels in the blood, making it an efficient and reliable method.
Step 3: Pulse oximetry is widely used in clinical settings due to its accuracy and convenience.
Step 4: In contrast, the other options are not direct methods for assessing SaO2. Incentive spirometry helps improve lung function, ABG measures blood pH and gases, and peak flow measures airflow in the lungs.
Which of the following signs may be revealed in a client with tonsillar infection by a visual examination if group A streptococci is the cause?
- A. White patches on the tonsils
- B. Hemorrhage in the tonsils
- C. Hypertrophied tonsils
- D. Bleeding in the tonsils
Correct Answer: A
Rationale: The correct answer is A. White patches on the tonsils are characteristic of streptococcal infections, such as strep throat. B (hemorrhage) and D (bleeding) are not typical findings in streptococcal infections. C (hypertrophied tonsils) may occur but is not specific to group A streptococci.
Which of the following serum lab values is a risk factor for the development of atherosclerosis?
- A. LDL 150 mg/dL
- B. Triglycerides 140 mg/dL
- C. Cholesterol 190 mg/dL
- D. HDL 100mg/dL
Correct Answer: A
Rationale: The correct answer is A: LDL 150 mg/dL. LDL cholesterol is known as "bad" cholesterol, and high levels are a risk factor for atherosclerosis. LDL can build up in the arteries, leading to plaque formation and narrowing of blood vessels. Elevated LDL levels increase the risk of cardiovascular disease.
Summary:
B: Triglycerides 140 mg/dL - Elevated triglycerides are a risk factor for heart disease, but not as directly linked to atherosclerosis as LDL.
C: Cholesterol 190 mg/dL - Total cholesterol includes both HDL and LDL, so this value alone does not specify the risk factor for atherosclerosis.
D: HDL 100mg/dL - High levels of HDL are actually considered beneficial as it is known as "good" cholesterol and helps to remove LDL from the bloodstream, reducing the risk of atherosclerosis.