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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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Correct Answer is ["A","D","E"]

No explanation

A. Place the client in high-Fowler's position. B. Administer epinephrine to the client. C. Administer oxygen to the client. D. Obtain a prescription for a diuretic. E. Stop the transfusion.

Correct Answer is ["A","C","E"]

Explanation

A. Place the client in high-Fowler's position: Placing the client in high-Fowler's position (sitting up at a 90-degree angle) can help improve oxygenation by optimizing lung expansion. This position facilitates better respiratory mechanics and can be beneficial for clients experiencing respiratory distress.

B. Administering epinephrine to the client: Epinephrine is not indicated for the management of fluid overload or transfusion reactions characterized by respiratory symptoms such as TRALI. Therefore, this action is not appropriate in this scenario.

C. Administer oxygen to the client: Hypoxia is a serious concern and requires immediate intervention. Administering oxygen will help improve oxygenation and alleviate respiratory distress.

D. Obtaining a prescription for a diuretic: While diuretics may be indicated in some cases of fluid overload, their use should be guided by the healthcare provider's assessment and prescription. Obtaining a prescription for a diuretic may be considered after the transfusion has been stopped and the healthcare provider has evaluated the client.

E. Stop the transfusion: The presence of lung crackles, hypoxia, and distended neck veins suggests fluid overload, which can be a sign of transfusion-related acute lung injury (TRALI) or circulatory overload. Stopping the transfusion is essential to prevent further fluid overload and worsening of respiratory symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer medications to a client. At which of the following times should the nurse compare the medication administration record and the medication label? (Select all that apply.)

Correct Answer is ["A","D","E"]

A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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