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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 ["A","B","D"]

Explanation

A. Decreased skin turgor: When a client is dehydrated (fluid volume deficit), the skin loses its elasticity. When pinched, the skin may "tent" or return to its original position slowly.

B. Dry mucous membranes: A lack of systemic fluid causes the mucous membranes of the mouth and nose to become dry, tacky, or parched.

C. Distended neck veins: Distended neck veins (Jugular Venous Distension) are a clinical sign of fluid volume excess or right-sided heart failure, as there is too much pressure/volume in the venous system. In deficit, neck veins are typically flat.

D. Blood pressure 88/62 mm Hg: A decrease in circulating blood volume (hypovolemia) leads to a drop in blood pressure (hypotension).

E. Heart rate 72/min: This is a normal heart rate. In a state of fluid volume deficit, the nurse would typically expect to find tachycardia (a heart rate greater than 100/min) as the heart attempts to compensate for low blood pressure and circulate the remaining volume more quickly.

A. Decreased edema formation B. Increased tissue metabolism C. Improved blood flow D. Reduced blood coagulation

Correct Answer is A

Explanation

A. Decreased edema formation: Cold causes vasoconstriction, which reduces capillary permeability and decreases fluid leakage into tissues (edema).

B. Increased tissue metabolism: Cold therapy decreases tissue metabolism and oxygen demand.

C. Improved blood flow: Cold therapy reduces blood flow through vasoconstriction.

D. Reduced blood coagulation: Cold can actually increase blood viscosity and does not therapeutically "reduce" coagulation in this context.

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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.