A nurse is assisting in the care of a client who has pneumonia.
Ensure the oxygen delivery system is at least 8 feet from any heat source.
Store the oxygen cylinder wrench with the oxygen tank.
Adjust the oxygen flow rate as needed to ease breathing.
Take antibiotic medication with or without food.
Take steroid medication in the morning.
Decrease the steroid dose each day.
Take antibiotics for 10 days.
Correct Answer : A,B,E,G
A. Ensure the oxygen delivery system is at least 8 feet from any heat source: Oxygen is flammable, and this safety measure helps prevent fire hazards in the home environment.
B. Store the oxygen cylinder wrench with the oxygen tank: Keeping the wrench with the tank ensures quick and easy access in case the oxygen needs to be turned on or off during an emergency.
C. Adjust the oxygen flow rate as needed to ease breathing: Clients should never adjust oxygen flow independently; flow rate changes must be prescribed and monitored by the healthcare provider to prevent complications like oxygen toxicity or hypoventilation.
D. Take antibiotic medication with or without food: This varies by antibiotic. Cefazolin, for example, was given IV in the hospital, and the oral form prescribed for home use might require food to reduce GI side effects; instructions should be drug-specific.
E. Take steroid medication in the morning: Steroids mimic the body’s natural cortisol rhythm; taking them in the morning minimizes insomnia and other endocrine side effects.
F. Decrease the steroid dose each day: Steroid tapering must follow a specific provider-prescribed regimen. Improper tapering can lead to adrenal insufficiency or withdrawal symptoms.
G. Take antibiotics for 10 days: Completing the full antibiotic course, even if symptoms improve, helps prevent antibiotic resistance and ensures complete eradication of the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hypoactivity: Hypoactive bowel sounds refer to reduced or diminished intestinal activity, often indicating slowed motility. These sounds are usually soft, infrequent, or absent, which contrasts with the loud, growling sounds described in this scenario.
B. Paralytic ileus: Paralytic ileus is a condition characterized by the absence of intestinal motility, resulting in no bowel sounds on auscultation. The presence of loud growling sounds indicates active bowel movements, making paralytic ileus an unlikely term.
C. Borborygmi: Borborygmi describes the loud, rumbling, growling, or gurgling sounds caused by the movement of gas and fluids through the intestines. These sounds are normal but can be louder than usual in cases of increased gastrointestinal activity, such as hunger or diarrhea.
D. Distention: Distention refers to the visible swelling or enlargement of the abdomen, often due to gas, fluid, or mass accumulation. It is a physical finding observed visually or by palpation, not a term for a type of bowel sound heard during auscultation.
Correct Answer is A
Explanation
A. Brittle hair: Malnutrition often leads to protein and micronutrient deficiencies, which impair hair growth and texture, resulting in dry, brittle, or thinning hair. This is a common visible sign in clients with poor nutritional status.
B. Yellow conjunctivae: Yellowing of the conjunctivae typically indicates jaundice due to liver dysfunction or hemolysis, not malnutrition from inflammatory bowel disease. It reflects bilirubin accumulation rather than nutrient deficiency.
C. Bradycardia: While bradycardia may occur in severe starvation or electrolyte imbalance, it is not a consistent or early indicator of malnutrition from inflammatory bowel disease. It requires further context to be clinically relevant.
D. Clubbing of the fingernails: Clubbing is associated with chronic hypoxia or pulmonary/cardiac conditions. It is not commonly linked to malnutrition or inflammatory bowel disease unless there are severe complications such as chronic anemia or hypoxia.
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