A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write?
Risk for infection related to chest x-ray procedure
Impaired gas exchange related to alveolar-capillary membrane changes
Risk for deficient fluid volume related to dehydration
Ineffective breathing pattern related to pneumonia
The Correct Answer is B
A. "Risk for infection related to chest x-ray procedure" is not an appropriate diagnosis because a chest x-ray is a diagnostic tool, and pneumonia itself is the concern for infection.
B. "Impaired gas exchange related to alveolar-capillary membrane changes" is correct as pneumonia causes inflammation and consolidation in the lungs, which directly impacts gas exchange.
C. "Risk for deficient fluid volume related to dehydration" does not apply specifically to pneumonia unless the patient presents signs of dehydration, which is not indicated in the scenario.
D. "Ineffective breathing pattern related to pneumonia" could also be a valid diagnosis, but the primary concern given the information provided is gas exchange impairment.
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Correct Answer is A
Explanation
A. The P wave represents atrial depolarization, which is initiated by the SA node, the heart's natural pacemaker.
B. The AV node is responsible for conducting impulses from the atria to the ventricles but does not initiate the P wave.
C. The Bundle of His transmits the electrical impulses to the ventricles but is not directly associated with the P wave.
D. Purkinje fibers are involved in ventricular depolarization, which corresponds to the QRS complex, not the P wave.
Correct Answer is ["A","B","C","D","F"]
Explanation
A. Applying knowledge of disease processes is essential in preventing the spread of infections and understanding transmission routes.
B. Proper disposal of supplies is crucial in minimizing the risk of cross-contamination and infection spread.
C. Checking the negative-pressure system is critical to ensure it functions properly to contain airborne pathogens.
D. Hand hygiene is a key practice in preventing infection and should be performed before and after patient contact in both scenarios.
E. This statement is misleading; while some precautions may overlap, there are specific differences that must be addressed in interventions for airborne versus contact precautions.
F. It is important for patients in airborne precautions to wear a mask during transportation to prevent the spread of infectious particles.