A nurse is caring for a client who has pneumonia on a medical-surgical unit.

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 []

Rationale

The nurse should administer a bronchodilator and prepare the client for intubation because the client is likely experiencing respiratory acidosis and respiratory distress. The nurse should then monitor for the correct placement of the ETT following intubation as well as the client's arterial blood gases to normalize.

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Correct Answer is B

Explanation

A. An intolerance to the feedings might cause discomfort, but it would not typically cause increasing pain, fever, and dyspnea. These symptoms are more indicative of a serious complication.
B. Esophageal perforation with fistula formation into the lung is the most likely cause of these symptoms. A perforation can lead to leakage of gastric contents into the pleural space or mediastinum, causing fever, pain, and respiratory distress. The formation of a fistula between the esophagus and the lung would lead to dyspnea.
C. Extension of the tumor into the aorta is a rare complication that would typically manifest with symptoms related to cardiovascular issues, not gastrointestinal symptoms like fever and dyspnea.
D. Leakage of fluids into the mediastinum is a possible cause of the symptoms, but esophageal perforation with a fistula into the lung is more directly linked to these specific symptoms, especially dyspnea.

A. Plan for periods of rest during activities, Monitoring the client's oxygen saturation B. Place the client on strict fluid restriction C. Placing the client on oxygen D. Restrict the client's smoking to 5 cigarettes per day

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

Explanation

A. Planning for periods of rest during activities and monitoring the client's oxygen saturation are essential interventions for a client with pneumonia. Rest helps conserve energy and reduces the workload on the respiratory system, while monitoring oxygen saturation ensures that the client is maintaining adequate oxygen levels, which is crucial in pneumonia.
B. Placing the client on strict fluid restriction is not appropriate for pneumonia. In fact, adequate hydration is important to help thin respiratory secretions and facilitate expectoration.
C. Placing the client on oxygen is often necessary for clients with pneumonia, especially if they are hypoxic or have difficulty maintaining adequate oxygen levels. Supplemental oxygen supports the respiratory system and improves oxygenation.
D. Restricting the client's smoking to 5 cigarettes per day is not an appropriate intervention. Smoking should be completely stopped to help reduce the risk of further respiratory complications. Smoking cessation is a priority in managing respiratory conditions like pneumonia

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Naxlex Comprehensive Predictor Exams

A patient who has undergone an esophagectomy for esophageal cancer develops increasing pain, fever, and dyspnea when a full liquid diet is started postoperatively. The nurse recognizes that these symptoms are most indicative of:

Correct Answer is B

Explanation

The nurse is caring for a client diagnosed with pneumonia. Which interventions should the nurse include in the plan of care? (Select All that Apply.)

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

Explanation

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