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A nurse is assisting in the care of a client who has pneumonia.

Exhibits
The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

Ensure the oxygen delivery system is at least 8 feet from any heat source.

Store the oxygen cylinder wrench with the oxygen tank.

Adjust the oxygen flow rate as needed to ease breathing.

Take antibiotic medication with or without food.

Take steroid medication in the morning.

Decrease the steroid dose each day.

Take antibiotics for 10 days.

Answer and Explanation

Correct Answer : A,B,E,G

A. Ensure the oxygen delivery system is at least 8 feet from any heat source: Oxygen is flammable, and this safety measure helps prevent fire hazards in the home environment.

B. Store the oxygen cylinder wrench with the oxygen tank: Keeping the wrench with the tank ensures quick and easy access in case the oxygen needs to be turned on or off during an emergency.

C. Adjust the oxygen flow rate as needed to ease breathing: Clients should never adjust oxygen flow independently; flow rate changes must be prescribed and monitored by the healthcare provider to prevent complications like oxygen toxicity or hypoventilation.

D. Take antibiotic medication with or without food: This varies by antibiotic. Cefazolin, for example, was given IV in the hospital, and the oral form prescribed for home use might require food to reduce GI side effects; instructions should be drug-specific.

E. Take steroid medication in the morning: Steroids mimic the body’s natural cortisol rhythm; taking them in the morning minimizes insomnia and other endocrine side effects.

F. Decrease the steroid dose each day: Steroid tapering must follow a specific provider-prescribed regimen. Improper tapering can lead to adrenal insufficiency or withdrawal symptoms.

G. Take antibiotics for 10 days: Completing the full antibiotic course, even if symptoms improve, helps prevent antibiotic resistance and ensures complete eradication of the infection.

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Correct Answer is ["A","B","D","E"]

Explanation

A. History of diabetes mellitus: Diabetes causes impaired blood flow and neuropathy, which delay wound healing by reducing oxygen and nutrient delivery to tissues and increasing infection risk.

B. Prealbumin level: A low prealbumin level reflects inadequate protein stores, which are critical for cellular repair, immune function, and the synthesis of collagen during wound healing.

C. Cholesterol level: While elevated cholesterol increases cardiovascular risk, it does not directly affect the biochemical processes involved in wound healing or tissue repair.

D. Mini Nutritional Assessment screening tool score: A low score indicates poor nutritional status, often linked with deficiencies in vitamins, minerals, and protein that are necessary for effective tissue repair and immune response.

E. History of malnutrition: Malnutrition results in diminished energy reserves and nutrient deficiencies, both of which weaken the body's capacity to regenerate tissue and fight infections, prolonging wound healing time.

F. History of hyperlipidemia: Hyperlipidemia contributes to atherosclerosis but is not directly associated with impaired wound healing or immune function necessary for tissue recovery.

A. WBC count B. Pain C. Abdominal findings D. Blood type E. Client's request for information F. Blood pressure G. Platelet count H. Oxygen saturation I. Client's PO intake J. Capillary refill

Correct Answer is ["B","E","F","H","I"]

Explanation

A. The WBC count was not provided in the nurse’s notes or diagnostic section. Without any indication of infection or abnormal lab values, there is no basis to report WBC.

B. Although the pain level is mild (2/10), it may be contributing to anxiety, increased heart rate (110/min), and elevated BP (158/96 mm Hg). Report in context as part of a comprehensive assessment. Also, confirming that the pain is not worsening or atypical in nature is essential preoperatively.

C. The abdomen is soft, rounded, non-distended, with no tenderness, and active bowel sounds in all four quadrants — all normal postoperative readiness findings for abdominal surgery.

D. Knowing the blood type is routine pre-op procedure and is not an abnormal or urgent finding that needs immediate reporting. It is only relevant if transfusion is anticipated, which is not suggested here.

E. The client is requesting further details about the risks and benefits of surgery, which raises a legal and ethical concern about informed consent. The provider must ensure the client fully understands the procedure, otherwise surgery cannot proceed.

F. This is significantly elevated compared to baseline (126/74). Pre-op hypertension can increase surgical and anesthesia risk and should be evaluated further. It may be due to anxiety, pain, or another condition.

G. Platelet count values were not given in the scenario. Without abnormal lab results or bleeding concerns, there is no indication to report this.

H. This is lower than the previous baseline (97%). An SpO₂ < 94% on room air can signal underlying respiratory issues, atelectasis, sedation effects, or cardiac dysfunction, all of which should be addressed preoperatively.

I. The client ate breakfast at 0730 before a scheduled procedure, violating NPO (nothing by mouth) protocol. This significantly increases the risk of aspiration under anesthesia and must be reported immediately. The surgery may need to be rescheduled.

J. Capillary refill < 2 seconds is normal, indicating adequate peripheral perfusion. No issues with circulation are noted, so there's no reason to notify the provider.

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A nurse is assisting in the care of a client who has pneumonia. Exhibits The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","D","E"]

Explanation

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Explanation

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A nurse is assisting in the care of a client who has pneumonia.

Exhibits
The nurse is reinforcing discharge teaching with the client and their caregiver. Which of the following information should the nurse include? Select all that apply.