A nurse is assessing a client who has pneumonia. Which of the following manifestations should the nurse expect?

Crackles.

Crepitus.

Stridor.

Decreased fremitus.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Crackles are adventitious lung sounds that can be heard on auscultation and are commonly associated with pneumonia. They are caused by the movement of air through fluid-filled or collapsed alveoli, indicating inflammation and infection in the lungs.

Choice B rationale:

Crepitus is a different respiratory finding and is not typically associated with pneumonia. Crepitus is a crackling or grating sensation that can be felt under the skin, often caused by subcutaneous emphysema or gas trapped in the tissues, not within the lungs.

Choice C rationale:

Stridor is a harsh, high-pitched sound heard during inspiration and is usually indicative of upper airway obstruction, not pneumonia. It can be caused by conditions such as croup or anaphylaxis.

Choice D rationale:

Decreased fremitus is not a specific manifestation of pneumonia. Fremitus is the vibration felt when the patient speaks and is transmitted through the chest wall. In pneumonia, increased fremitus may be observed due to the consolidation of lung tissue with fluid or pus, not decreased fremitus.

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Correct Answer is C

Explanation

Choice A rationale:

Taking sitz baths can provide comfort but will not directly address the transmission of herpes simplex virus type 2 (HSV-2). It is essential to avoid sexual activity during outbreaks to prevent spreading the infection to a partner.

Choice B rationale:

Cleansing lesions with 1/2 strength peroxide may irritate the affected area and delay healing. The recommended approach is to use gentle soap and water to clean the lesions.

Choice C rationale:

"I will avoid sexual activity until my lesions are healed.”. This statement indicates an understanding of the teaching because HSV-2 is highly contagious during active outbreaks. Avoiding sexual activity during this time is essential to prevent transmitting the virus to a partner.

Choice D rationale:

"I am not contagious once I begin antiviral medication.”. This statement is incorrect as antiviral medications can help manage outbreaks but do not eliminate the risk of transmission entirely. The virus remains contagious until lesions are completely healed.

A. Administer the medication no faster than 100 mg/min. B. Monitor plasma phenytoin levels to establish the therapeutic range. C. Add the medication to the existing IV solution. D. Monitor the client for hypertension.

Correct Answer is A

Explanation

Choice A rationale:

Administering phenytoin IV no faster than 100 mg/min is crucial to prevent adverse effects such as cardiovascular collapse or severe hypotension. Rapid administration of phenytoin can cause cardiac arrhythmias and should be avoided.

Choice B rationale:

Monitoring plasma phenytoin levels to establish the therapeutic range is a necessary action in managing the client's seizure disorder, but it does not pertain to the specific administration of phenytoin via intermittent bolus.

Choice C rationale:

Adding the medication to the existing IV solution is not appropriate for phenytoin administration. Phenytoin should be administered separately and not mixed with other IV solutions to maintain its stability and prevent interactions.

Choice D rationale:

Monitoring the client for hypertension is not directly related to the administration of phenytoin via intermittent bolus. Hypertension is not a common adverse effect of this medication. However, blood pressure should be monitored as part of routine care for any client on antiepileptic therapy.

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A nurse is assessing a client who has pneumonia. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a female client who has herpes simplex virus type 2. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is planning to administer phenytoin IV via intermittent bolus to a client who has a seizure disorder and is receiving a continuous IV infusion of dextrose 5% in water (D5W). Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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