The nurse is reviewing the Nurses Notes in the female clients medical record.

Click to highlight the findings that indicate the client is progressing in their plan of care. To deselect a finding, click on the finding again.

Nurses' Notes

Day 4, 1030

Client states is easier to breathe and I'm not as short of breath" Lung sounds still diminished with crackles. No wheezes detected. Client is on oxygen at 1L/min via nasal cannula and oxygen saturation is 92%. Client reports pleuritic chest pain as 3 on a scale of 0 to 10. Cough is productive and sputum is yellow. Drinking 2 L/per day, voided 200 ml of clear yellow urine.

Client states is easier to breathe and I'm not as short of breath

Lung sounds still diminished with crackles

Client is on oxygen at 1L/min via nasal cannula and oxygen saturation is 92%

Client reports pleuritic chest pain as 3 on a scale of 0 to 10

Cough is productive and sputum is yellow

Answer and Explanation

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

Rationale for correct choices

• Client states "It is easier to breathe and I'm not as short of breath": The client’s subjective report of improved breathing reflects a positive response to oxygen therapy, antibiotics, and pulmonary interventions. Decreased dyspnea indicates that oxygenation and lung function are improving. This aligns with expected outcomes for pneumonia management and shows clinical progress.

• Oxygen at 1 L/min via nasal cannula with oxygen saturation of 92%: The reduction in supplemental oxygen from 2 L/min to 1 L/min, while maintaining oxygen saturation above 90%, indicates improved respiratory status and better gas exchange. This demonstrates that the client is stabilizing and responding to therapy, a key indicator of progress.

• Client reports pleuritic chest pain as 3 on a scale of 0 to 10: A decrease in pain from 6/10 to 3/10 shows that inflammation and respiratory effort are improving. Lower pain levels enhance the client’s ability to cough, deep breathe, and participate in pulmonary exercises, supporting recovery.

Rationale for incorrect findings

• Lung sounds still diminished with crackles: Although lung sounds are still diminished with crackles, this finding indicates residual congestion in the lungs rather than full resolution. Crackles can persist for several days after pneumonia begins to improve and do not yet signify complete clinical improvement.

• Cough productive with yellow sputum: The presence of yellow sputum indicates ongoing infection and inflammation. While productive coughing helps clear secretions, the sputum color shows that the infection has not fully resolved, so this is not a definitive indicator of progress.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Arterial blood gases: ABGs assess acid-base balance and respiratory status, which are not directly affected by lithium therapy. They are not required prior to initiating lithium.

B. Total cholesterol: Lithium does not significantly impact lipid metabolism, so baseline cholesterol is not necessary before starting therapy.

C. Thyroid hormones: Lithium can affect thyroid function and may cause hypothyroidism over time. Evaluating baseline thyroid hormone levels prior to therapy helps monitor for potential adverse effects and guides ongoing management.

D. Hemoglobin: Lithium does not directly affect hemoglobin levels, so baseline hemoglobin measurement is not required for safe initiation of therapy.

A. Decreased reflexes B. Weight gain of 1.4 kg (3b) C. Increased urinary output D. Jugular vein distention

Correct Answer is A

Explanation

A. Decreased reflexes: Loop diuretics can cause electrolyte imbalances, particularly hypokalemia and hypomagnesemia. Hypokalemia can lead to neuromuscular changes, including decreased reflexes, muscle weakness, and potentially life-threatening cardiac arrhythmias. This is an adverse effect that requires prompt assessment and intervention.

B. Weight gain of 1.4 kg (3 lb): Weight gain in heart failure may indicate fluid retention, but a loop diuretic typically promotes diuresis. A small weight gain of 1.4 kg is not immediately indicative of an adverse effect from the medication itself and may reflect other factors, such as fluid shifts or diet.

C. Increased urinary output: Increased urinary output is the intended therapeutic effect of loop diuretics. It indicates that the medication is working to reduce fluid overload rather than an adverse effect.

D. Jugular vein distention: Jugular vein distention is a sign of fluid overload in heart failure. While it may indicate insufficient therapeutic response, it is not a direct adverse effect of the loop diuretic. Monitoring and adjusting therapy may be necessary, but it is not a medication-related complication.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for lithium carbonate. Prior to administering the first dose, which of the following laboratory values should the nurse evaluate?

Correct Answer is C

Explanation

A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

Correct Answer is A

Explanation

A nurse is teaching a client and their family about home hospice care. Which of the following information should the nurse include in the teaching?

A nurse is caring for a child in the emergency department. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is most at risk for developing _________ due to ________

A nurse is preparing to administer vancomycin to a client who has an infected wound. The nurse should plan to monitor for which of the following adverse reactions?

A nurse is caring for a client who is requesting treatment for a gambling disorder. Which of the following medications should the nurse expect the provider to prescribe?

A nurse is providing discharge teaching about disease prevention to a client who has active tuberculosis. Which of the following should the nurse include?

A nurse is caring for a dent in a cardiology clinic. Complete the following sentence by using the lists of options. Based on the client data, the nurse should identify the client is experiencing _____________ as evidenced by ______________.

A nurse is caring for a client who is taking allopurinol. The nurse should monitor which of the following laboratory findings to determine the effectiveness of the medication?

A nurse is planning to admit a client who has hyperthyroidism. To which of the following rooms should the nurse assign this client?