Prepare for your NCLEX exam with this question of the day on bacterial pneumonia. Test your knowledge on oxygen saturation and the use of supplemental oxygen.
The nurse is caring for a 70 year-old patient admitted to the hospital from a skilled nursing facility for treatment of bacterial pneumonia. Based upon the information in the electronic health record, which action should the nurse take first?
| Electronic Health Record (EHR) | |
| Current Vital Signs | Temperature 101.5 ℉ (38.6℃) Heart Rate 105/min Respirations 26/min Blood pressure 140/85 mmHg Oxygen saturation 91% on room air |
| Respiratory Assessment | Coarse crackles to left lower lobe |
| Vaccination Status | Pneumococcal polysaccharide vaccine: Last dose 7 years ago |
| Pending Diagnostic Tests | Chest X-ray Complete blood count Electrolyte panel |
A. Apply supplemental oxygen via nasal cannula
B. Administer the patient’s prescribed metoprolol
C. Educate the patient on receiving the pneumococcal polysaccharide vaccine
D. Administer oral acetaminophen as prescribed
Scroll down for the correct answers!
The correct answer to today’s NCLEX-RN® Question are…
A. Apply supplemental oxygen via nasal cannula
Rationale: This is the priority action since the patient’s oxygen saturation is below 95% on room air. In patients with pneumonia, there can be impaired gas exchange. According to the airway, breathing, circulation (ABC) model, problems with airway and breathing should be addressed first.
Major Takeaway
The nurse should use clinical judgment to take action related to pneumonia by implementing the solutions that address the highest priority. The nurse’s priority action for a patient with pneumonia who is hypoxic is to apply supplemental oxygen to achieve an oxygen saturation of 95% or above. Patients with pneumonia are at risk for hypoxia because the airway and alveoli can fill with fluid and exudate resulting in poor gas exchange. According to the airway, breathing, circulation (ABC) model, problems with airway and breathing should be addressed first followed by other problems (e.g., fever, vaccination).
Incorrect answer explanations
B. Administer the patient’s prescribed metoprolol
Rationale: While the patient’s heart rate is elevated, it is likely due to the pneumonia infection. Another priority action should be taken first according to the airway, breathing, circulation (ABC) model.
C. Educate the patient on receiving the pneumococcal polysaccharide vaccine
Rationale: Older adult patients from a community setting, like a skilled nursing facility,, are prone to pneumonia and should be vaccinated with the updated pneumococcal polysaccharide every five years. Since this patient had their last dose seven years ago, they will likely need another dose, however, there is another action that should be taken first.
E. Administer oral acetaminophen as prescribed
Rationale: Although this patient has a fever due to the infectious process of pneumonia and could benefit from acetaminophen administration, there is another action that should be performed first.
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