Nokea
The nurse is assessing a 79-year-old client diagnosed with pneumonia. Which signs and symptoms should the nurse expect to assess in the client?
- A. Confusion and lethargy.
- B. High fever and chills.
- C. Frothy sputum and edema.
- D. Bradypnea and jugular vein distention.
Correct Answer: A
Rationale: Elderly pneumonia patients often present with confusion/lethargy (A) due to hypoxia. Fever/chills (B) are less common in the elderly, frothy sputum/edema (C) suggest heart failure, and bradypnea/JVD (D) are unrelated.
You may also like to solve these questions
The client in the intensive care unit diagnosed with end-stage chronic obstructive pulmonary disease has a Swan-Ganz mean pulmonary artery pressure of 35 mm Hg. Which health-care provider order would the nurse question?
- A. Administer intravenous fluids of normal saline at 125 mL/hr.
- B. Provide supplemental oxygen per nasal cannula at 2 L/min.
- C. Continuous telemetry monitoring with strips every four (4) hours.
- D. Administer a loop diuretic intravenously every six (6) hours.
Correct Answer: A
Rationale: A mean pulmonary artery pressure of 35 mm Hg indicates pulmonary hypertension, common in end-stage COPD. IV fluids at 125 mL/hr (A) risk fluid overload and worsening right heart strain, so this order should be questioned. Oxygen (B), telemetry (C), and diuretics (D) are appropriate to manage hypoxia, monitor cardiac status, and reduce fluid overload.
The day shift charge nurse on a medical unit is making rounds after report. Which client should be seen first?
- A. The 65-year-old client diagnosed with tuberculosis who has a sputum specimen to be sent to the laboratory.
- B. The 76-year-old client diagnosed with aspiration pneumonia who has a clogged feeding tube.
- C. The 45-year-old client diagnosed with pneumonia who has a pulse oximetry reading of 92%.
- D. The 39-year-old client diagnosed with bronchitis who has an arterial oxygenation level of 89%.
Correct Answer: D
Rationale: SpO2 89% (D) indicates significant hypoxia, requiring immediate assessment. TB sputum (A), clogged tube (B), and SpO2 92% (C) are less urgent.
Which observation best indicates that a client with a pneumothorax is developing a tension pneumothorax?
- A. The trachea is deviated.
- B. The client is coughing.
- C. The chest is asymmetrical.
- D. The client reports sharp pain.
Correct Answer: A
Rationale: Tracheal deviation is a hallmark sign of tension pneumothorax, indicating mediastinal shift due to increased intrathoracic pressure.
For the client who has just had a pneumonectomy, what is a temporary, expected outcome of thoracic surgery?
- A. The client's ability to speak
- B. Chest numbness
- C. Impaired swallowing
- D. Sore throat
Correct Answer: B
Rationale: Chest numbness is an expected temporary outcome due to nerve disruption during thoracic surgery.
Where on the client should the nurse position the sensor of the pulse oximeter to obtain an accurate measurement?
- A. Apply it to the client's finger.
- B. Apply it to the client's palm.
- C. Clip it to the client's earlobe.
- D. Wrap it around the client's leg.
Correct Answer: A
Rationale: The finger is the most common and reliable site for pulse oximetry, providing accurate oxygenation readings.