Practice Question
A nurse was assessing a patient
Answer Choices:
Rationale:
🌟 CONDITION MOST LIKELY EXPERIENCING
🟢 Pneumonia
🔷 Green, thick sputum with productive cough strongly suggests a bacterial lower respiratory tract infection, which is typical of pneumonia rather than other postoperative complications.
🔷 Low-pitched rhonchi in lung bases indicate mucus accumulation and airway inflammation, consistent with pneumonia.
🔷 Tachypnea (slight but present) is an early sign of respiratory compromise, commonly seen in pneumonia due to impaired gas exchange.
🔷 The patient has risk factors for postoperative pneumonia, including obesity, immobility, and a history of smoking, all of which reduce lung expansion and clearance of secretions after surgery.
🔷 Pulmonary embolism typically presents with sudden chest pain, clear sputum, and severe dyspnea, which are not described here, and surgical site infection would present with local redness, swelling, and purulent wound drainage—none of which are noted.
🌟 ACTIONS TO TAKE
✅ 1. Administer oxygen 2L via nasal cannula
🔷 Postoperative pneumonia impairs alveolar gas exchange, leading to hypoxemia; oxygen administration improves tissue perfusion and oxygenation.
🔷 Low-flow oxygen via nasal cannula is appropriate for a mild to moderate respiratory compromise, helping maintain SpO₂ > 92%.
🔷 Supplemental oxygen also reduces the work of breathing, preventing fatigue and potential respiratory failure.
🔷 Continuous oxygen administration is important until the infection is controlled and respiratory function stabilizes.
🔷 Oxygen is a priority intervention in pneumonia because hypoxia can lead to organ dysfunction if not corrected promptly.
✅ 2. Administer acetaminophen for fever
🔷 Fever increases metabolic demand and oxygen consumption, which can worsen hypoxemia in a patient already experiencing respiratory compromise.
🔷 Acetaminophen is appropriate for controlling fever and mild pain without causing respiratory depression (unlike opioids).
🔷 Reducing fever also improves patient comfort and may help stimulate better lung expansion and coughing, aiding in clearing secretions.
🔷 Antipyretic therapy supports the immune system by reducing excessive metabolic strain, especially crucial in postoperative patients.
🔷 Controlling fever indirectly reduces cardiovascular strain, important in patients with hypertension and postoperative stress.
🌟 PARAMETERS TO MONITOR
✅ 1. Respiration rate
🔷 The respiratory rate is a sensitive early indicator of worsening pneumonia and impending respiratory distress.
🔷 Tachypnea often correlates with increased work of breathing and hypoxemia, requiring prompt intervention if it worsens.
🔷 Monitoring the respiratory rate helps determine if oxygen therapy is adequate or if further interventions (e.g., respiratory therapy, chest physiotherapy) are needed.
🔷 Persistent tachypnea may also indicate sepsis or systemic infection progression, which requires urgent escalation of care.
🔷 Frequent respiratory assessment ensures early recognition of deterioration, preventing respiratory failure.
✅ 2. Oxygen saturation
🔷 Pulse oximetry provides real-time assessment of oxygenation and is crucial in monitoring pneumonia progression.
🔷 A drop in SpO₂ below 92% may indicate worsening alveolar consolidation or ventilation-perfusion mismatch, necessitating oxygen adjustment.
🔷 Tracking oxygen saturation also assesses the effectiveness of oxygen therapy and guides weaning when appropriate.
🔷 Continuous monitoring prevents silent hypoxemia, which may occur before severe respiratory distress is clinically apparent.
🔷 Improvement in oxygen saturation is one of the earliest signs of clinical recovery in pneumonia.
Want to practice more questions like this?
This question is from RN Medical Surgical-Summer 2025 which contains 67 questions.
More Questions from This Exam
The nurse cares for a client with Addison's disease.
Answer Choices:
A client arrives in the clinic and states that their sexual partner told them to come and get checked for chlamydia. Place the nurse’s action in the order they should be completed, from first priority to last. Click an option, hold and drag it to the desired position. or click on option to Highlight it and move it up or down in the order using the arrows to the left.
Answer Choices:
The nurse educates a client about the administration of Insulin for control of diabetes mellitus type 1. What statements made by the client indicate that the nurse needs to reinforce the education provided? Select all that apply.
Answer Choices:
The nurse educates a client regarding the use of nitrofurantoin for the treatment of pyelonephritis. What statement made by the client indicates further teaching is required?
Answer Choices:
The nurse cares for a client that presents with severe abdominal pain radiating to the back that occurred after drinking alcohol. The client reports vomiting does not relieve the pain. The client's blood pressure is 90/52, heart rate 128, and respiratory rate 36. What is the priority action by the nurse?
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Medical-Surgical
- Answer Choices: 0