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 D
Explanation
A. Vision is not commonly affected by vancomycin, so it is not a priority to assess.
B. Heart tones are not directly impacted by vancomycin and do not require immediate monitoring unless there are specific cardiovascular concerns.
C. Bowel sounds are not directly influenced by vancomycin and do not need to be prioritized in this case.
D. Vancomycin is known to be ototoxic, especially in high doses or with prolonged use, so monitoring for signs of hearing loss or tinnitus is essential to prevent potential irreversible damage.
Correct Answer is B
Explanation
A. Performing movements until the patient reports pain is inappropriate in passive range of motion, as the goal is to maintain joint function without causing discomfort.
B. Moving each joint to the point of resistance helps to maintain flexibility and prevent stiffness without causing harm, making this the appropriate technique.
C. Repeating movements five times by the patient is not applicable for passive range of motion, which is performed by the nurse on a patient who cannot do it themselves.
D. While smooth movements are essential, they should not be done quickly; the focus should be on the patient's comfort and safety, avoiding rapid or jerky motions.