A nurse is caring for a client who has pneumonia.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Clostridium difficile infection is likely because the client has pneumonia and is receiving ceftriaxone, an antibiotic known to disrupt gut flora and cause opportunistic infections like C. difficile. The presence of frequent, liquid, foul-smelling stools further supports this diagnosis.
Myocardial infarction is unlikely because while the client has chest pain, it is pleuritic and related to inspiration rather than the typical crushing, non-pleuritic chest pain seen in an MI. There is no mention of radiating pain, diaphoresis, or hemodynamic instability.
Pulmonary edema is unlikely since it typically presents with dyspnea, crackles throughout the lung fields, pink frothy sputum, and signs of fluid overload such as peripheral edema and weight gain. The client’s symptoms do not align with this condition.
Pulmonary embolism is also unlikely, as it presents with sudden-onset dyspnea, pleuritic chest pain, tachycardia, and often calf swelling or a history of deep vein thrombosis. The client lacks the risk factors and clinical signs of PE.
Placing the client on contact precautions is necessary because C. difficile is highly contagious and spreads through the fecal-oral route. Gloves and gowns should be used to prevent transmission.
Obtaining a stool culture is necessary to confirm the presence of C. difficile toxins in the stool, which is essential for accurate diagnosis and treatment.
Requesting a prescription for an anticoagulant is not necessary because the client does not show any signs of thromboembolic disease such as deep vein thrombosis or pulmonary embolism. Anticoagulation could increase the risk of bleeding in the gastrointestinal tract, which would worsen the diarrhea.
Requesting a prescription for a diuretic is not needed because the client is more likely to be dehydrated due to diarrhea. Diuretics would exacerbate fluid loss and electrolyte imbalances.
Restricting fluids is not appropriate because dehydration is a major concern with C. difficile infection. Instead, fluid intake should be encouraged to prevent complications from excessive fluid loss.
Level of consciousness should be monitored because severe dehydration and electrolyte imbalances can lead to confusion, weakness, and altered mental status. While altered mental status can occur with severe dehydration or sepsis, it is not the primary concern at this stage.
Potassium level should be monitored because diarrhea can cause significant potassium loss, leading to hypokalemia, which can result in muscle weakness, cardiac arrhythmias, and fatigue.
Urine output is not the most specific parameter for monitoring C. difficile infection. While dehydration is a concern, tracking electrolyte levels and neurological status is more critical.
Calf swelling is not relevant since the client does not have signs or risk factors for deep vein thrombosis or pulmonary embolism.
Weight: C. difficile infection can cause significant fluid loss due to persistent diarrhea, leading to dehydration and weight loss. Tracking daily weight helps assess hydration status and the effectiveness of fluid replacement therapy.

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Correct Answer is D

Explanation

A. Develop a quality improvement program for nurses involved in medication administration errors. While quality improvement programs are essential, implementing a targeted program without first analyzing the root causes of errors may not effectively address the underlying issues. A broader review of system-wide factors contributing to medication errors is necessary before designing an intervention.
B. Require staff nurses to demonstrate competency by passing a medication administration examination. Competency assessments may help identify knowledge gaps, but they do not address system-based errors such as workload issues, unclear protocols, or distractions during medication administration. A root cause analysis should be conducted first to ensure that interventions target the actual sources of errors.
C. Provide an inservice on medication administration to all the nurses. Educational sessions can reinforce safe practices, but without identifying the specific factors contributing to errors, they may not be effective. Training should be tailored to address the findings from an initial review of the medication errors.
D. Review the events leading up to each medication administration error. The first step in continuous quality improvement is conducting a thorough analysis of the errors, identifying patterns, and determining root causes. This helps in designing targeted interventions, whether they involve process changes, additional training, or improved safety protocols.

A. Auscultate lungs for the presence of breath sounds B. Assess baseline level of consciousness C. Assess for the presence of circumoral cyanosis D. Determine that the pulse oximetry is greater than 95%.

Correct Answer is A

Explanation

A. Auscultate lungs for the presence of breath sounds: This is the priority action following endotracheal intubation, as it directly assesses the effectiveness of the intubation. Auscultating the lungs allows the nurse to confirm that the endotracheal tube is properly positioned in the trachea and that air is reaching the lungs. Abnormal breath sounds, such as decreased or absent sounds on one side, may indicate improper placement or complications like a pneumothorax, making this assessment critical for patient safety.
B. Assess baseline level of consciousness: While assessing the client's level of consciousness is important for evaluating their overall neurological status, it is not the immediate priority following intubation. Changes in consciousness can be influenced by various factors, including sedation or hypoxia, but ensuring proper airway placement and ventilation is more urgent to prevent respiratory compromise.
C. Assess for the presence of circumoral cyanosis: Circumoral cyanosis can indicate inadequate oxygenation, but it may not be immediately apparent after intubation. This assessment is important, but it is secondary to confirming that breath sounds are present and that the airway is secure. Identifying airway placement issues is more crucial before evaluating for signs of hypoxia.
D. Determine that the pulse oximetry is greater than 95%: Monitoring pulse oximetry is essential for assessing oxygen saturation and identifying potential hypoxia. However, if the endotracheal tube is not properly placed, the pulse oximetry may not accurately reflect the client’s respiratory status. Therefore, ensuring proper ventilation through auscultation of breath sounds takes precedence over solely relying on pulse oximetry readings.

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Naxlex Comprehensive Predictor Exams

A nurse is serving on a continuous quality improvement (CQI) committee that has been assigned to develop a program to reduce the number of medication administration errors following a sentinel event at the facility. Which of the following strategies should the committee plan to initiate first?

Correct Answer is D

Explanation

A nurse is caring for a client immediately following endotracheal intubation. The nurse should assess the client for complications by performing which of the following priority action?

Correct Answer is A

Explanation

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