A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) and is diagnosed with pneumonia. The client has been on a long-term regimen of methylprednisolone. Which precautions should the nurse take to prevent complications? Select all that apply.
Ensure the client receives adequate amounts of fluids
Check the client's mouth for stomatitis
Assess the client's mental status
Monitor for signs of hypokalemia
Monitor the clients blood glucose levels
Monitor the clients blood pressure for hypotension
Correct Answer : A,B,C,D,E,F
Ensure the client receives adequate amounts of fluids: This is important to maintain hydration and thin respiratory secretions, making it easier for the client to cough and clear the airways. Check the client's mouth for stomatitis: Methylprednisolone can increase the risk of developing oral candidiasis (thrush) or stomatitis, which can cause discomfort and interfere with oral intake. Regular mouth checks can help identify these conditions early for appropriate management. Assess the client's mental status: Pneumonia, particularly in individuals with pre-existing lung disease like COPD, can lead to hypoxemia, which may affect mental status. It is important to monitor the client's mental status, as changes in cognition or confusion can be indicators of hypoxia and require prompt intervention.
Monitor for signs of hypokalemia: Methylprednisolone, like other corticosteroids, can cause electrolyte imbalances, including hypokalemia (low potassium levels). Hypokalemia can have various effects on the body, including muscle weakness and cardiac dysrhythmias. Regular monitoring of potassium levels and signs of hypokalemia is important for timely management. Monitor the client's blood glucose levels: Methylprednisolone can increase blood glucose levels, particularly in individuals with pre-existing diabetes or impaired glucose tolerance. Regular monitoring of blood glucose levels is necessary to ensure proper glycemic control and prevent hyperglycemia-related complications.
Monitor the client's blood pressure for hypotension: Corticosteroids like methylprednisolone can cause fluid retention, leading to an increase in blood pressure. However, sudden withdrawal of corticosteroids can result in adrenal insufficiency and hypotension. Close monitoring of blood pressure is necessary to identify any significant changes and adjust the medication regimen accordingly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The red tag is used to identify patients with critical injuries who require immediate medical attention. These individuals have life-threatening conditions that, with prompt medical intervention, have a higher chance of survival.
The triage color code system typically follows the following priority order:
1. Red tag: Immediate or emergent care needed for life-threatening injuries or conditions.
2. Yellow tag: Urgent care needed for significant injuries or conditions that are not immediately life-threatening.
3. Green tag: Non-urgent care needed for minor injuries or illnesses that can wait for medical treatment.
4. Black tag: Comfort care or deceased, as the injuries or conditions are incompatible with life or resources are not available for treatment.
Correct Answer is ["B","C","D","E","F"]
Explanation
The normal physiological changes of aging that the nurse can expect in an older adult during a musculoskeletal assessment include:
● Widened Gait: With age, there can be a natural widening of the gait due to changes in balance and stability.
● Kyphosis: Kyphosis refers to an increased curvature of the thoracic spine, commonly known as a "hunchback" appearance, which can occur due to changes in the vertebral bones and intervertebral discs.
● Slowed movement: Older adults may experience a natural decline in their movement speed due to changes in muscle strength, coordination, and reaction time. ● Muscle atrophy: Age-related muscle atrophy, or loss of muscle mass, can occur, particularly if the older adult leads a sedentary lifestyle or has other underlying health conditions.
● Decreased joint ROM (Range of Motion): Older adults may experience a gradual decrease in joint flexibility and range of motion due to changes in the joints, ligaments, and surrounding tissues. This can affect their ability to move joints fully.
It's important to note that while some older adults may develop arthritis, it is not considered a normal physiological change of aging. Arthritis refers to the inflammation and degeneration of joints, which can occur due to various factors, including age, genetics, and lifestyle.
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