A client is diagnosed with pneumonia and has been hospitalized for several days. A priority nursing diagnosis for this client is which of the following?

1. Altered oral mucous membranes, related to dry mouth
2. Activity intolerance, related to oxygen supply imbalance
3. Knowledge deficit, related to medication regimen
4. Ineffective airway clearance, related to increased secretions


Correct Answer: 4
Rationale 1: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need..
Rationale 2: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need.
Rationale 3: Prioritizing care must begin with the basic needs. This option is appropriate but does not match the primary need
Rationale 4: Prioritizing care must begin with the basic needs, in this case, the airway.

Nursing

You might also like to view...

A nurse is assessing pain in a 3-year-old child. Which of the following would be most appropriate for the nurse to use? Select all that apply

A) Number scale B) Color scale C) Letter scale D) Facial expression scale E) Shape scale

Nursing

A patient is to receive IV immunoglobulin. Prior to administration, the nurse should implement which intervention?

A) Only administer immunoglobulin through a central line B) Administer IV immunoglobulin at 10 mL/minute C) Administer furosemide prior to and with immunoglobulin D) Weigh the patient before administration to determine onset of edema

Nursing

A client asks the nurse how to prevent gout. Which responses are appropriate by the nurse? (Select all that apply.) Note: Credit will be given only if all correct choices and no incorrect choices are selected

1. Treatment with antigout medications 2. Dietary management 3. Avoidance of drugs that worsen gout 4. Decreased fluid intake 5. Using hypoglycemia medications

Nursing

The nurse assesses the client might be experiencing toxicity from colchicine. Which statement by the client would most likely confirm the nurse's suspicion?

1. "My joints hurt more." 2. "I have nausea, vomiting, and abdominal pain every day." 3. "I don't see as well as I used to, and my taste has changed." 4. "I wake up at night with muscle cramps."

Nursing