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 B
Explanation
A. The pharmacist is responsible for filling prescriptions accurately but does not have control over how the nurse interprets the prescription once received.
B. The nurse has the ultimate responsibility for verifying and administering medications safely, including clarifying unclear prescriptions before administration.
C. The hospital has policies and systems in place to reduce errors, but accountability for individual actions lies with the nurse administering the medication.
D. The health care provider is responsible for prescribing medications accurately; however, the nurse must confirm and clarify any unclear prescriptions before administration.
Correct Answer is B
Explanation
A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.