Practice Question
A patient has been transferred to your unit from the respiratory intensive care unit, where he has been for the past 2 weeks recovering from pneumonia. He is receiving oxygen via 4 L nasal cannula. His respiratory rate is 26 breaths/min, and his oxygen saturation is 92%. In planning his care, which information is most helpful in determining your priority nursing interventions?
Answer Choices:
Correct Answer:
Patient's perception of dyspnea
Rationale:
🟢 The patient’s subjective perception of dyspnea (shortness of breath) is the most helpful in determining priority nursing interventions, because it provides real-time insight into how well the client is tolerating their current respiratory status.
🟢 Clients with pneumonia may still be recovering, and their work of breathing can increase quickly even if vital signs appear stable.
🟢 Baseline vital signs are useful for comparison, but they do not reflect the patient’s immediate breathing comfort or distress.
🟢 Activity orders guide safe mobility but are not the priority when assessing respiratory compromise.
🟢 The medication list is important for planning, but it does not immediately guide acute interventions related to oxygenation.
🟢 Dyspnea is often the earliest and most sensitive indicator of respiratory compromise, so prioritizing the client’s report ensures timely interventions such as adjusting oxygen, positioning, or notifying the provider.
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This question is from NurseLogic Knowledge and Clinical Judgment Advanced which contains 75 questions.
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From Exam
NurseLogic Knowledge and Clinical Judgment Advanced
75 Questions
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- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 4