A nurse is caring for a client.

Exhibits

Which of the following actions should the nurse take? (Select all that apply.)

Wear a mask when caring for the client.

Place the client in private room.

Encourage the client to increase fluid intake.

Place the client on contact precautions.

Prepare to administer an antibiotic to the client.

Answer and Explanation

Correct Answer : A,B,C

A. Wear a mask when caring for the client: This is an important action to prevent the spread of influenza, which is transmitted via respiratory droplets. Wearing a mask helps protect both the healthcare provider and other patients from potential exposure to the virus, especially in the early stages of the disease when the client is most contagious.
B. Place the client in a private room: This action is recommended to minimize the risk of transmitting the influenza virus to other patients. Isolating the client in a private room can help control the spread of infection, making it a necessary measure in this situation.
C. Encourage the client to increase fluid intake: Adequate hydration is essential for clients with influenza to help alleviate fever and maintain overall health. Increasing fluid intake supports the immune system and helps prevent complications such as dehydration, so encouraging the client to drink more fluids is appropriate.
D. Place the client on contact precautions: While contact precautions are essential for preventing the spread of infections transmitted by direct contact, they are not specifically necessary for influenza, which is primarily airborne and droplet transmitted. Standard precautions, including droplet precautions, are sufficient for managing a client with influenza.
E. Prepare to administer an antibiotic to the client: This action is not appropriate because influenza is a viral infection, and antibiotics are ineffective against viruses. Treatment for influenza typically involves antiviral medications if indicated, supportive care, and symptom management rather than antibiotics. Therefore, this option should not be included in the actions the nurse takes.

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Correct Answer is C

Explanation

A. Use of Passy Muir speaking valve: While this is an important aspect of communication for a client who has undergone a laryngectomy, it is not the highest priority at the time of discharge. The use of the speaking valve can be addressed after ensuring that the client is equipped to handle immediate safety concerns and emergencies related to their condition.
B. Phone number of healthcare provider to report complications: Providing the client with contact information for their healthcare provider is essential for ongoing support and to address any concerns that may arise after discharge. However, this information is secondary to ensuring the client can effectively communicate their condition and limitations, particularly in an emergency situation.
C. Emergency personal identification that client is unable to speak: This is the highest priority for discharge teaching because it directly addresses the client’s safety. Having emergency identification is crucial for informing healthcare providers and first responders about the client's inability to speak, especially in situations where communication may be vital for receiving appropriate care. Ensuring that the client can communicate their condition in emergencies takes precedence over other aspects of post-operative care.
D. Ability to perform tracheostomy care: While it is important for the client to be educated on tracheostomy care to ensure ongoing health and safety, this teaching can be considered after addressing immediate safety needs. The ability to care for the tracheostomy is vital but does not take priority over having emergency identification that communicates the client’s needs to others who may not be aware of their condition.

A. pH 7.55, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 24 mEq/L B. pH 7.30, PaCO2 60 mm Hg, PaO2 70 mm Hg, HCO3 30 mEq/L C. pH 7.40, PaCO2 40 mm Hg, PaO2 94 mm Hg, HCO3 22 mEq/L D. pH 7.38, PaCO2 45 mm Hg, PaO2 88 mm Hg, HCO3 26 mEq/L

Correct Answer is B

Explanation

A. pH 7.55, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 24 mEq/L: This ABG finding indicates respiratory alkalosis, as evidenced by the elevated pH and decreased PaCO2. In progressive COPD, clients typically retain carbon dioxide rather than blow it off, so this finding would not be expected in a patient with chronic respiratory issues.
B. pH 7.30, PaCO2 60 mm Hg, PaO2 70 mm Hg, HCO3 30 mEq/L: This is the most consistent finding for a client with progressive COPD. The low pH indicates acidosis, and the elevated PaCO2 suggests respiratory acidosis due to carbon dioxide retention, a common problem in COPD. The elevated HCO3 indicates a compensatory metabolic response, as the body attempts to retain bicarbonate to buffer the acidosis.
C. pH 7.40, PaCO2 40 mm Hg, PaO2 94 mm Hg, HCO3 22 mEq/L: These values indicate a normal ABG, which would not be expected in a client with progressive COPD. Patients with chronic lung disease typically present with acid-base imbalances due to respiratory failure, so this finding suggests the client is not exhibiting the expected complications of COPD.
D. pH 7.38, PaCO2 45 mm Hg, PaO2 88 mm Hg, HCO3 26 mEq/L: Although these findings show mild acidosis, the PaCO2 is within normal limits, indicating that this patient may not be experiencing significant respiratory failure. In advanced COPD, one would expect to see a higher PaCO2 and more pronounced acidosis, making this option less characteristic of a patient with progressive COPD compared to option B.

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A nurse is caring for a client. Exhibits Which of the following actions should the nurse take? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to discharge a client who is a status post-operative laryngectomy. The nurse should recognize which of the following discharge teaching is the highest priority?

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Explanation

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Correct Answer is B

Explanation

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A nurse is caring for a client.

Exhibits

Which of the following actions should the nurse take? (Select all that apply.)