Author Question: The nurse is caring for a patient with pneumonia who complains of shortness of breath. Further ... (Read 78 times)

bobypop · **on:** Jun 25, 2018

The nurse is caring for a patient with pneumonia who complains of shortness of breath.

Further assessment reveals an oxygen saturation of 89 on room air, 28 respirations/min with bilateral crackles in lung bases, blood pressure of 160/94, and a pulse rate of 102 beats/min. Which nursing diagnosis is priority for this patient?
a. Activity Intolerance
b. Impaired Gas Exchange
c. Ineffective Cardiopulmonary Tissue Per-fusion
d. Self-Care Deficit: Bathing and Hygiene

Question 2

The home health nurse is making an initial call on a newly diagnosed tuberculosis (TB) patient. The patient lives with his wife and child. Which infection control instructions should the nurse include in the teaching plan? (Select all that apply.)

a. Place contaminated tissues in sealable plastic bag.
b. Take medications exactly as directed.
c. Implement airborne precautions.
d. Wash hands frequently.
e. Wear a mask when in crowds.

johnpizzaz · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

B
While all nursing diagnoses may apply to this patient, impaired gas exchange is the highest priority because this is the underlying problem for the other nursing diagnoses, as well as physi-ologically the highest priority.

Answer to Question 2

A, B, D, E
Instructions should include information about disposing of contaminated materials in sealed bags, taking medications exactly as directed, utilizing frequent hand hygiene, and donning a mask when in crowds. Since the family has already been exposed, taking airborne precautions is unnecessary.