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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Check for a positive Babinski reflex.: This is used to assess upper motor neuron dysfunction, not balance.
B. Have the client perform heel-to-toe walking.: This (tandem walking) tests cerebellar function and the client's ability to maintain an upright posture while moving.
C. Perform the Romberg test.: The Romberg test assesses balance by having the client stand with feet together and eyes closed; significant swaying indicates a loss of balance.
D. Have the client lie in bed and use his heel to draw a line on the opposite shin.: This (heel-to-shin test) assesses coordination, but since the client is lying down, it does not test balance.
E. Perform Weber's test.: This is a hearing test used to determine if sound is heard equally in both ears.
Correct Answer is B
Explanation
A. "You will have to sign a release form to perform the care yourself.": There is no standard legal release form required for family involvement in postmortem hygiene.
B. "I will assist you in any way I can during this process.": This is a culturally sensitive and therapeutic response. Allowing the family to participate in postmortem care can provide closure and honor religious or personal rituals.
C. "This care takes place after the client leaves the facility.": Postmortem care is performed immediately after death in the facility to prepare the body for the family to view and for transport.
D. "A licensed health care worker must perform postmortem care.": While the nurse is responsible for the overall process, there is no law preventing family members from assisting or performing the care themselves if they wish.
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