A nurse is participating in interprofessional team meeting for a client. Which of the following information about the client should the nurse include?

The client’s vital signs are checked every 8 hr

The client has developed difficulty ambulating

The client has state-sponsored health insurance

The client's next dressing change is scheduled in 4 hr.

Answer and Explanation

The Correct Answer is B

A) The client’s vital signs are checked every 8 hr: While vital signs are an important aspect of the client's health, this information is routine and doesn't provide new insights that would impact the overall plan of care during an interprofessional team meeting. It’s important to focus on changes in the client’s condition or specific concerns that require collaboration.

B) The client has developed difficulty ambulating: This is critical information to share during the interprofessional team meeting because it may require input from physical therapists, occupational therapists, or other specialists. Difficulty ambulating can indicate a need for reassessment of the client's mobility plan, and other team members need to be informed to develop appropriate interventions.

C) The client has state-sponsored health insurance: While the client’s insurance status is relevant for financial and discharge planning, it is not directly related to the clinical management or care coordination that would be discussed in an interprofessional team meeting. The focus should be on the client’s clinical condition and needs.

D) The client's next dressing change is scheduled in 4 hr: Although the dressing change is important for continuity of care, this is more of a task-related detail rather than critical clinical information that requires interprofessional discussion. The focus in a team meeting should be on the client's progress, challenges, and needs, not just routine care tasks.

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Correct Answer is D

Explanation

A) Weight loss: Weight loss is not a sign of fluid overload; rather, it is more indicative of dehydration or insufficient nutritional intake. Fluid overload typically leads to weight gain due to the accumulation of excess fluid in the body, so weight loss would not be a manifestation of this condition.

B) Decreased skin turgor: Decreased skin turgor is a common sign of dehydration, not fluid overload. When a person is dehydrated, the skin loses its elasticity, and it takes longer to return to its normal position after being pinched. This is the opposite of what is seen in fluid overload, where excess fluid causes the skin to appear more swollen or taut.

C) Decreased blood pressure: Decreased blood pressure is more commonly associated with hypovolemia (low fluid volume) or dehydration, rather than fluid overload. In fluid overload, blood pressure may actually rise due to the increased volume of circulating blood, not decrease.

D) Crackles heard in the lungs: Crackles, or rales, heard in the lungs are a classic sign of fluid overload, particularly when the excess fluid accumulates in the lungs (pulmonary edema). This can occur due to the heart's inability to pump effectively, leading to fluid retention in the lungs. Therefore, crackles in the lungs are a key manifestation of fluid overload.

A. I will take my inhaler treatment before each meal and at bed time." B. I will rinse my mouth and gargle with water after each inhaler treatment." C. I should use my inhaler when I have an asthma attack." D. I should use my inhaler before exercising."

Correct Answer is B

Explanation

A) I will take my inhaler treatment before each meal and at bedtime:
Budesonide is a corticosteroid inhaler used for asthma management, but it is not specifically required to be taken before meals. The timing of inhaler use should be directed by the healthcare provider based on the individual treatment plan. Taking the inhaler at meals is not typically necessary unless specifically instructed, and there is no standard requirement for it to be taken at bedtime either.

B) I will rinse my mouth and gargle with water after each inhaler treatment:
Rinsing the mouth and gargling with water after using an inhaled corticosteroid, like budesonide, is an essential step to reduce the risk of developing oral thrush, a fungal infection. Corticosteroids can promote fungal growth in the mouth, so rinsing helps to clear any residual medication from the mouth and prevent this complication. This statement demonstrates an accurate understanding of the proper use of the inhaler.

C) I should use my inhaler when I have an asthma attack:
Budesonide is a maintenance medication used to control asthma symptoms over the long term, not for immediate relief during an asthma attack. For acute asthma attacks, a fast-acting bronchodilator like albuterol is used, not a corticosteroid like budesonide. The adolescent’s statement reflects a misunderstanding of the purpose of budesonide, which is for prevention and long-term control.

D) I should use my inhaler before exercising:
Using an inhaler before exercise may be appropriate for clients who have exercise-induced bronchoconstriction or asthma, but budesonide is not typically used as a pre-exercise medication. Instead, a short-acting bronchodilator is used before exercise to prevent asthma symptoms during activity. Budesonide is generally used for long-term asthma management rather than for acute symptom relief.

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