A nurse is assisting in the care of a client who has pneumonia in the medical unit.

Exhibits

Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)

Take antibiotics for 10 days.

Ensure the oxygen delivery system is at least 8 feet from any heat source.

Decrease the steroid dose each day.

Take antibiotic medication with or without food.

Adjust the oxygen flow rate as needed to ease breathing.

Take steroid medication in the morning.

Answer and Explanation

Correct Answer : A,B

Choice A rationale: It is important for the client to complete the full course of antibiotics to ensure the infection is fully treated and to prevent antibiotic resistance.

Choice B rationale: Keeping the oxygen delivery system at least 8 feet from any heat source is crucial for safety to prevent the risk of fire.

Choice C rationale: Decreasing the steroid dose each day is not relevant in this case since there is no mention of the client being on steroids for the pneumonia treatment.

Choice D rationale: While taking antibiotic medication with or without food can be important, the specific instruction for this medication should be based on the pharmacist's or provider's recommendation. However, this option is not the best answer compared to completing the full course of antibiotics.

Choice E rationale: Adjusting the oxygen flow rate as needed to ease breathing should only be done under medical supervision. Clients are typically instructed to use a prescribed oxygen flow rate, and adjustments should not be made without consulting a healthcare provider.

Choice F rationale: Taking steroid medication in the morning can help reduce side effects, but again, this option is not relevant since the client's current treatment does not include steroids.

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Correct Answer is D

Explanation

Choice A rationale

Applying cornstarch powder to the perineal area can lead to clumping and skin irritation, especially in a moist environment. It is not recommended for managing fecal incontinence.

Choice B rationale

Turning the client every 4 hours is important for preventing pressure ulcers but does not directly address fecal incontinence. Frequent turning should be combined with other measures for skin protection.

Choice C rationale

Cleansing the perineal area with povidone-iodine solution can be harsh and drying to the skin. It is not typically recommended for routine care of fecal incontinence.

Choice D rationale

Placing a moisture barrier ointment over the perineal area protects the skin from irritation and breakdown caused by fecal matter. It creates a protective layer, which is essential in managing fecal incontinence.

A. Hyperactive bowel sounds are present. B. Stomach contents are yellowish green in color. C. Aspirated stomach contents' pH measures 6.5. D. Residual volume of stomach contents measures 90 mL.

Correct Answer is C

Explanation

Choice A rationale

Hyperactive bowel sounds indicate increased gastrointestinal activity, often associated with conditions like gastroenteritis or diarrhea. While it requires monitoring, it is not immediately concerning in the context of administering medications via a gastrostomy tube.

Choice B rationale

Yellowish-green stomach contents suggest the presence of bile, a normal finding in gastric aspirates. It indicates that the tube is correctly placed in the stomach, which is crucial before administering medications.

Choice C rationale

A pH of 6.5 for aspirated stomach contents suggests that the tube might be dislocated into the respiratory tract or intestines, as normal gastric pH ranges from 1.5 to 3.5. Reporting this finding is critical to avoid complications.

Choice D rationale

A residual volume of 90 mL is within the acceptable range for most clients with gastrostomy tubes. High residual volumes (usually over 200 mL) are more concerning and may require intervention.

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A nurse is assisting in the care of a client who has pneumonia in the medical unit. Exhibits Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)

Nursing Test Bank

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Explanation

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Explanation

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A nurse is assisting in the care of a client who has pneumonia in the medical unit.

Exhibits

Which of the following information should the nurse include in discharge teaching for the client? (Select all that apply)