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A nurse is caring for a client who has pneumonia.

Exhibit 1

Medication Administration Record

Day 1, 1500:

Cefazolin 500 mg every 12 hr IV

Dexamethasone 15 mg every 6 hr IV

Day 3, 1200:

Discontinue dexamethasone 15 mg every 6 hr IV Prednisone 40 mg PO daily

Day 4, 1500:

Discontinue cefazolin 500 mg every 12 hr IV
The nurse is providing discharge teaching for the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

Antibiotic medication can be taken with or without food,

The steroid dose will decrease each day.

Adjust the oxygen flow rate as needed to ease breathing.

Antibiotic therapy should be taken for 10 days.

Store the oxygen cylinder wrench with the oxygen tank.

Steroid medication should be taken in the morning.

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

Answer and Explanation

Correct Answer : B,C,F,G

A. Antibiotic medication can be taken with or without food.

This statement is not specifically relevant to the discharge teaching for this client with pneumonia. However, the nurse should provide specific instructions regarding the administration of the antibiotic (cefazolin), which is typically administered intravenously in a healthcare setting and may not be taken orally at home.

B. The steroid dose will decrease each day.

Explanation: This information ensures that the client and caregiver are aware of the tapering regimen for the steroid medication (prednisone), which is essential to prevent adrenal insufficiency and other potential adverse effects associated with abrupt discontinuation.

C. Adjust the oxygen flow rate as needed to ease breathing.

Explanation: This information educates the client and caregiver on how to manage oxygen therapy effectively at home, ensuring optimal oxygen delivery and respiratory support.

D. Antibiotic therapy should be taken for 10 days.

The duration of antibiotic therapy for pneumonia depends on the specific antibiotic prescribed and the severity of the infection. The nurse should provide clear instructions based on the healthcare provider's prescription and guidelines.

E. Store the oxygen cylinder wrench with the oxygen tank.

While storing the oxygen cylinder wrench with the oxygen tank is a good practice, it is not directly related to discharge teaching for this client with pneumonia.

F. Steroid medication should be taken in the morning.

Explanation: Taking steroid medication (prednisone) in the morning helps minimize disruption of the body's natural cortisol rhythm and reduces the risk of insomnia associated with steroid use.

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

Explanation: Proper storage and placement of the oxygen delivery system reduce the risk of fire hazards associated with oxygen therapy, promoting safety within the home environment.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A.Placing gauze under the flanges of the tracheostomy tube is not recommended because it can create a breeding ground for bacteria and increase the risk of infection.Pre-cut gauze pads should be used to avoid loose fibers from entering the stoma.

B.Full-strength hydrogen peroxide is too harsh and can cause skin irritation or damage. When performing tracheostomy care, the skin around the stoma should be cleaned with a mild saline solution.

C.A collar with hook-and-loop fastenersis commonly used to secure the tracheostomy tube in place. This collar should be snug enough to hold the tube securely but not too tight to cause discomfort or restrict airflow. The collar helps prevent accidental dislodgement of the tracheostomy tube, ensuring it remains properly positioned.

D.Sterile gloves should be worn when cleaning the inner cannula of the tracheostomy tube to minimize the risk of introducing pathogens.

A. The client adjusts the head of their bed to 90°, B. The client drinks their thickened juice with a straw. C. The client tucks their chin when they swallow. D. The client takes frequent breaks while eating.

Correct Answer is B

Explanation

A. The client adjusts the head of their bed to 90°: Adjusting the head of the bed to 90° is a correct action for clients with dysphagia as it helps facilitate swallowing by promoting an upright position, reducing the risk of aspiration.

B. The client drinks their thickened juice with a straw.

Drinking thickened liquids with a straw is not recommended for clients with dysphagia. Straws can increase the risk of aspiration, as they bypass the natural protection mechanisms in the mouth and throat that help prevent liquids from entering the airway. Therefore, the nurse should intervene and provide the client with an appropriate drinking cup instead of a straw when consuming thickened liquids.

C. The client tucks their chin when they swallow: Tucking the chin when swallowing is a recommended technique for clients with dysphagia, as it helps close off the airway and directs the food or liquid toward the esophagus, reducing the risk of aspiration.

D. The client takes frequent breaks while eating: Taking frequent breaks while eating is a beneficial strategy for clients with dysphagia, as it allows them to rest and swallow safely without feeling rushed or overwhelmed by large amounts of food or liquid.

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Correct Answer is B

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