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

The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include?
Select all that apply.

Store the oxygen cylinder wrench with the oxygen tank.

Take steroid medication in the morning.

Decrease the steroid dose each day.

Take antibiotic medication with or without food.

Adjust the oxygen flow rate as needed to ease breathing.

Ensure the oxygen delivery system

Take antibiotics for 10 days.

Answer and Explanation

Correct Answer : A,B,D,F

A. Store the oxygen cylinder wrench with the oxygen tank.: The wrench is necessary to open the oxygen tank in an emergency or when changing tanks. Keeping it with the tank ensures it is immediately available for the client or caregiver.

B. Take steroid medication in the morning.: Prednisone (a corticosteroid) can cause insomnia and restlessness. Taking it in the morning aligns with the body's natural circadian rhythm of cortisol production and helps prevent sleep disturbances.

C. Decrease the steroid dose each day.: The prescription states "40 mg PO daily for 5 days." The nurse should instruct the client to take the full dose as prescribed. While steroids are often tapered, the client should not self-taper unless specifically directed by the provider's prescription.

D. Take antibiotic medication with or without food.: Cephalexin can be taken without regard to meals. However, if the medication causes GI upset, taking it with food can help mitigate nausea.

E. Adjust the oxygen flow rate as needed to ease breathing.: Oxygen is considered a medication. The client must maintain the prescribed flow rate (3 L/min) and should never adjust it without a provider's order, as excessive oxygen can be harmful to some patients.

F. Ensure the oxygen delivery system is at least 8 feet from any heat source.: Oxygen supports combustion. To prevent fires, tanks and concentrators must be kept away from open flames, space heaters, candles, or gas stoves. Standard safety guidelines usually recommend 5 to 10 feet (8 feet is a safe middle ground).

G. Take antibiotics for 10 days.: The prescription specifically states "every 6 hr for 5 days." Taking medications for longer than prescribed is incorrect instruction.

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Correct Answer is D

Explanation

A. Notify the charge nurse of the client's condition.: While necessary, it is not the first action in an acute assessment situation.

B. Review the client's most recent SaO2 level in the medical record.: This provides context but does not address the client's current acute respiratory distress.

C. Check the client's medical records to see which medications were recently administered.: This delays immediate intervention for a potentially unstable client.

D. Recheck the client's SaO2 level after having the client cough and clear their throat.: This is a simple, immediate nursing intervention to clear the airway and ensure the reading is accurate and not affected by secretions.

A. Brittle hair B. Yellow conjunctivae C. Clubbing of the fingernails D. Bradycardia

Correct Answer is A

Explanation

A. Brittle hair: Protein-calorie malnutrition often leads to hair that is dull, dry, and brittle, and may eventually fall out (alopecia) due to the lack of nutrients required for hair follicle health.

B. Yellow conjunctivae: This is a sign of jaundice (icterus), usually indicating liver dysfunction or hemolysis, rather than general malnutrition.

C. Clubbing of the fingernails: This is typically a sign of chronic hypoxia (low oxygen levels) associated with cardiac or pulmonary disease, not specifically malnutrition.

D. Bradycardia: While severe starvation can slow the heart rate, tachycardia (a fast heart rate) is a more common finding in the early stages of malnutrition or dehydration.

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A nurse is assisting in the care of a client who has pneumonia. The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

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

The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include?
Select all that apply.