The nurse is caring for a patient who is hospitalized for ...

[crazycityslicker]

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. Imbalanced nutrition r/t poor appetite and increased metabolic needs
  c. Ineffective airway clearance r/t thick secretions in trachea and bronchi
  d. Knowledge deficit r/t use of nebulizer and inhaled bronchodilators

Question 2

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.

[hugthug12]

Answer to Question 1

ANS: C
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.

Answer to Question 2

ANS: A
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 into the lung space until the new collection device is attached.