A 60-year-old male client is admitted to the medical-surgical unit. The client is experiencing a worsening of symptoms over the last 24 hours. The client's initial presentation was similar to previous days, but his condition has deteriorated.
Based on the evolution of the client’s condition and the provided exhibits, select all that apply. Which of the following actions should the nurse include in the client's care plan?
Implement airborne precautions.
Prepare for possible intubation and mechanical ventilation.
Monitor the client’s blood glucose levels frequently.
Administer IV antibiotics as prescribed.
Ensure strict hand hygiene before and after client contact.
Increase fluid intake to help with sputum production.
Prepare to assist with a chest tube insertion.
Correct Answer : B,C,D,E,F
Choice A rationale: Implementing airborne precautions is not necessary in this case. The client’s symptoms and the progression of their condition suggest a severe respiratory infection, possibly pneumonia, but there is no indication that the infection is airborne.
Airborne precautions are typically reserved for diseases that are spread through tiny droplets in the air, such as tuberculosis, measles, or chickenpox.
Choice B rationale: The client’s worsening respiratory distress, evidenced by increased shortness of breath, use of accessory muscles for breathing, decreased oxygen saturation, and changes in sputum, indicate that the client may require intubation and mechanical ventilation. This would ensure that the client’s airway remains open and that they receive adequate oxygen.
Choice C rationale: The client has a history of well-managed diabetes mellitus. Given the stress of the illness and the initiation of corticosteroid therapy (which can raise blood glucose levels), it would be important to monitor the client’s blood glucose levels frequently.
Choice D rationale: The client has been prescribed Levofloxacin, an antibiotic, which should be administered as prescribed. Given the client’s symptoms and the progression of their condition, it is likely that they have a bacterial infection. Antibiotics are critical for treating bacterial infections.
Choice E rationale: Ensuring strict hand hygiene before and after client contact is a standard precaution in all healthcare settings to prevent the spread of infection.
Choice F rationale: Increasing fluid intake can help thin out the sputum, making it easier for the client to cough it up. This can help improve the client’s respiratory function.
Choice G rationale: There is no current indication for a chest tube insertion. While the client’s chest X-ray shows extensive consolidation and possible pleural effusion, the notes do not indicate that the effusion is large enough to require drainage at this time. A chest tube would be considered if the effusion was large and causing significant respiratory distress, which is not clearly the case here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
The nurse should stop the IV infusion. The client has manifestations of IV infiltration, which occurs when IV fluid enters the surrounding tissue. Stopping the IV infusion and removing the IV catheter can reduce the risk for further tissue damage.
Choice B rationale
The nurse should elevate the client’s left arm. Elevation can help decrease swelling and reduce the risk for tissue damage.
Choice C rationale
The nurse should apply heat to the client’s left hand. Heat can help reduce swelling and promote comfort.
Choice D rationale
Starting a new IV in the client’s left hand is not recommended at this point. The nurse should first manage the infiltration and then assess the need for a new IV3.
Correct Answer is B
Explanation
Choice A rationale
The client was admitted three days ago. This statement is factual, but it does not directly address the current condition of the client’s pressure injury. The time of admission is not as relevant as the progression and treatment of the wound. Therefore, while this choice is accurate, it is not the most critical piece of information in this context.
Choice B rationale
The pressure injury was at stage 4. This is the correct answer. Stage 4 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage or bone.
The presence of slough, eschar, and tunnels, as well as the size of the wound, are consistent with a stage 4 pressure ulcer. The treatment provided, including debridement and negative
pressure wound therapy, is also typical for this stage of pressure injury. Therefore, this choice accurately describes the client’s condition.
Choice C rationale
The client reported pain as a 2 on a scale from 0 to 10. While it’s important to monitor the client’s pain levels, this information alone does not provide a comprehensive understanding of the client’s condition. Pain can be subjective and varies from person to person. A score of 2 indicates minor pain, which is manageable and does not significantly interfere with the client’s daily activities. However, this does not negate the severity of a stage 4 pressure injury.
Choice D rationale
The dressing was reapplied and sealed. This statement describes one aspect of the wound care process. Negative pressure wound therapy involves the application of a vacuum through a special sealed dressing. The dressing is crucial in creating a moist healing environment, reducing edema, and promoting wound healing. However, the reapplication and sealing of the dressing alone do not provide a complete picture of the client’s condition or the severity of the pressure injury.
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