A nurse is caring for a client who has pneumonia.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Use many "I's" in the message: Overusing the word "I" can make a message seem self-centered and less engaging. Instead, a balanced approach that highlights accomplishments and skills without excessive focus on oneself is more effective. Using "I" sparingly helps maintain professionalism and keeps the focus on how the nurse's qualifications meet the needs of potential employers.
B. Be sure to remove your address and phone number and replace it with your email because your resume will be on the internet: While protecting personal information is important, completely removing contact details is not advisable. Including a professional email along with appropriate contact information allows potential employers to reach out directly. Instead of removing all personal contact information, consider using a professional email address while maintaining other essential contact details as needed.
C. Save your resume in .docx format: While .docx is a commonly used format, it is not the best choice for online job applications, as some applicant tracking systems may not parse it correctly. Instead, saving the resume as a PDF is often recommended, as it preserves formatting and is widely accepted by employers. Therefore, this option may not be the most effective recommendation.
D. Focus on selling yourself: This is a good recommendation for a nurse searching for a job. Effectively presenting skills, experiences, and accomplishments demonstrates to potential employers how the nurse can add value to their organization. A well-crafted resume and cover letter should highlight the nurse's qualifications, passion for nursing, and ability to meet the specific needs of the position and the organization. This approach can significantly enhance the chances of securing an interview and ultimately a job.
Correct Answer is A
Explanation
A. Increase the oxygen flow rate. The client is experiencing worsening hypoxia, tachypnea, and dyspnea, indicating progressive respiratory distress due to pulmonary embolism (PE). Increasing the oxygen flow rate is the priority to improve oxygenation, reduce the work of breathing, and prevent further hypoxemia. Providing supplemental oxygen helps stabilize the client while preparing for further interventions. The client’s rapidly deteriorating condition, suggests potential hemodynamic instability. Immediate provider notification ensures urgent evaluation for interventions such as anticoagulation, thrombolytics, or intensive monitoring.
B. Increase the oxygen flow rate, then elevate the head of the bed. While elevating the head of the bed can assist breathing by improving lung expansion, it does not address the underlying pathophysiology of PE. Notifying the provider is more critical, as the client may need immediate pharmacologic or procedural interventions to prevent further deterioration.
C. Administer pain medication, then notify the healthcare provider. Pain relief is important, but in acute respiratory distress, oxygenation and circulatory stability take precedence. Narcotics can depress respiratory drive and worsen hypoxia, making them a lower priority until the client’s respiratory status is stabilized.
D. Encourage deep breathing exercises, then check capillary refill. Deep breathing is beneficial for lung expansion but is not an effective treatment for acute PE. The priority is ensuring oxygenation and immediate medical intervention rather than focusing on routine assessments like capillary refill, which do not directly address the emergency.
E. Elevate the head of the bed, then apply compression stockings. Elevating the head of the bed may help ease breathing, but it is a supportive measure rather than a primary intervention. Compression stockings are used for DVT prevention, not for managing an active embolism, making them inappropriate as a priority action in this scenario.
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