The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing
diagnosis has the highest priority?
a. Activity intolerance r/t generalized weakness and hypoxemia
b. Impaired nutritional intake r/t poor appetite and increased metabolic needs
c. Impaired airway clearance r/t thick secretions in trachea and bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators
Give this one a try later!
, c. Impaired airway clearance r/t thick secretions in trachea and bronchi.
Airway maintenance and patency is the highest priority for all patients,
especially patients with respiratory disorders. Oxygenation is the most
important human need. The other diagnoses can apply once the patient's
airway is kept patent.
The nurse is caring for a patient with a history of left-sided congestive heart failure
who is acutely short of breath. The nurse hears fine crackles throughout both lung
fields and notes that the patient's pulse oximetry is only 88% on 4 L of oxygen. What is
the priority intervention of the nurse?
a. Administer the ordered intravenous diuretic.
b. Prepare for insertion of a chest tube.
c. Suction secretions from the patient's respiratory tract.
d. Have the patient use the ordered incentive spirometer.
Give this one a try later!
a. Administer the ordered intravenous diuretic.
The patient's respiratory distress is due to pulmonary edema and fluid
overload from left-sided congestive heart failure. A patient with heart
failure may be on diuretics. A diuretic will pull the excess fluid out of the
body through the urine and relieve the patient's distress. A chest tube is not
needed as the fluid is within the alveoli rather than between the lung and
chest wall. Suctioning and use of an incentive spirometer will not address
fluid overload or improve the patient's symptoms.
The nurse is caring for a patient with high cholesterol who has been prescribed
atorvastatin (Lipitor). Which laboratory result indicates that the patient has been taking
the medication as ordered and following the physician's dietary recommendations?
a. Serum triglyceride level 325 mg/dL
, b. High-density lipoproteins (HDL) 56 mg/dL
c. Low-density lipoproteins (LDL) 155 mg/dL
d. Total cholesterol level 185 mg/dL
Give this one a try later!
d. Total cholesterol level 185 mg/dL
A total cholesterol level higher than 200 mg/dL is considered a risk factor
for atherosclerosis, so a cholesterol level of 185 mg/dL indicates that the
patient has been compliant with the prescribed therapy. The other
laboratory results are abnormal and would not indicate compliance.
The nurse is caring for a patient with a chest tube who was transported to radiology
for testing. When the patient returns to the nursing unit, the transporter shows the
nurse the patient's chest tube collection device, which was badly damaged after
being caught in the elevator door. What is the priority action of the nurse?
a. Clamp the chest tube until the collection device is replaced.
b. Cover the insertion site with a new occlusive dressing.
c. Ensure that there is gentle bubbling in the water seal chamber.
d. Check the patient's lung sounds and pulse oximetry.
Give this one a try later!
a. Clamp the chest tube until the collection device is replaced.
The broken collection device may no longer be used to collect chest tube
drainage. Clamping the chest tube until the collection device is replaced
will prevent air from entering the lung space until the new collection
device is attached.
The preceptor is working with a new nurse to provide care for a patient with a chest
tube to relieve a pneumothorax. Which action by the new nurse indicates need for
diagnosis has the highest priority?
a. Activity intolerance r/t generalized weakness and hypoxemia
b. Impaired nutritional intake r/t poor appetite and increased metabolic needs
c. Impaired airway clearance r/t thick secretions in trachea and bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators
Give this one a try later!
, c. Impaired airway clearance r/t thick secretions in trachea and bronchi.
Airway maintenance and patency is the highest priority for all patients,
especially patients with respiratory disorders. Oxygenation is the most
important human need. The other diagnoses can apply once the patient's
airway is kept patent.
The nurse is caring for a patient with a history of left-sided congestive heart failure
who is acutely short of breath. The nurse hears fine crackles throughout both lung
fields and notes that the patient's pulse oximetry is only 88% on 4 L of oxygen. What is
the priority intervention of the nurse?
a. Administer the ordered intravenous diuretic.
b. Prepare for insertion of a chest tube.
c. Suction secretions from the patient's respiratory tract.
d. Have the patient use the ordered incentive spirometer.
Give this one a try later!
a. Administer the ordered intravenous diuretic.
The patient's respiratory distress is due to pulmonary edema and fluid
overload from left-sided congestive heart failure. A patient with heart
failure may be on diuretics. A diuretic will pull the excess fluid out of the
body through the urine and relieve the patient's distress. A chest tube is not
needed as the fluid is within the alveoli rather than between the lung and
chest wall. Suctioning and use of an incentive spirometer will not address
fluid overload or improve the patient's symptoms.
The nurse is caring for a patient with high cholesterol who has been prescribed
atorvastatin (Lipitor). Which laboratory result indicates that the patient has been taking
the medication as ordered and following the physician's dietary recommendations?
a. Serum triglyceride level 325 mg/dL
, b. High-density lipoproteins (HDL) 56 mg/dL
c. Low-density lipoproteins (LDL) 155 mg/dL
d. Total cholesterol level 185 mg/dL
Give this one a try later!
d. Total cholesterol level 185 mg/dL
A total cholesterol level higher than 200 mg/dL is considered a risk factor
for atherosclerosis, so a cholesterol level of 185 mg/dL indicates that the
patient has been compliant with the prescribed therapy. The other
laboratory results are abnormal and would not indicate compliance.
The nurse is caring for a patient with a chest tube who was transported to radiology
for testing. When the patient returns to the nursing unit, the transporter shows the
nurse the patient's chest tube collection device, which was badly damaged after
being caught in the elevator door. What is the priority action of the nurse?
a. Clamp the chest tube until the collection device is replaced.
b. Cover the insertion site with a new occlusive dressing.
c. Ensure that there is gentle bubbling in the water seal chamber.
d. Check the patient's lung sounds and pulse oximetry.
Give this one a try later!
a. Clamp the chest tube until the collection device is replaced.
The broken collection device may no longer be used to collect chest tube
drainage. Clamping the chest tube until the collection device is replaced
will prevent air from entering the lung space until the new collection
device is attached.
The preceptor is working with a new nurse to provide care for a patient with a chest
tube to relieve a pneumothorax. Which action by the new nurse indicates need for
