A nurse is caring for a client in the intensive care unit.

Exhibits

Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Most Likely Condition:

The client is most likely experiencing Hospital-acquired pneumonia ©. This is indicated by the recent admission for pneumonia, persistent cough with greenish sputum, increased WBC count, and bilateral infiltrates on the chest X-ray.

Actions to Take:

Administer IV antibiotics as prescribed (already in the provider’s prescriptions).
Perform chest physiotherapy © to help clear the lungs.

Parameters to Monitor:

Oxygen saturation (A) to ensure the client is maintaining adequate oxygen levels.
White blood cell count (D) to monitor the infection and response to antibiotics.

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Correct Answer is C

Explanation

Choice A rationale
Removing dentures or other oral appliances is not the most critical intervention for a client with severe obstructive sleep apnea (OSA) who has received an opioid analgesic. The priority is to ensure airway patency.
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention because it directly maintains airway patency and prevents respiratory compromise, which is crucial for a client with severe OSA2.
Choice D rationale
Putting and locking the side rails in place is important for safety but does not address the critical need to maintain airway patency in a client with severe OSA.

A. Smoking cessation. B. Regular exercise. C. Low-fat diet. D. Stress reduction.

Correct Answer is A

Explanation

Choice A rationale
Smoking cessation is the most important lifestyle modification for preventing and managing cardiac disease. Smoking is a major modifiable risk factor that can cause atherosclerosis, hypertension, arrhythmias, thrombosis, and myocardial infarction. Quitting smoking has a more direct effect on improving the function and structure of the blood vessels and heart.
Choice B rationale
Regular exercise is a beneficial lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While exercise helps in maintaining a healthy weight, reducing blood pressure, and improving overall cardiovascular health, smoking cessation has a greater impact on reducing the risk of cardiovascular events and mortality.
Choice C rationale
A low-fat diet is a useful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Although a low-fat diet helps in lowering cholesterol levels and reducing the risk of heart disease, smoking cessation has a stronger influence on lowering the levels of cholesterol and inflammation in the blood.
Choice D rationale
Stress reduction is a helpful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While stress reduction techniques such as relaxation exercises, meditation, and mindfulness can be beneficial for heart health, addressing smoking cessation is more urgent for individuals with a family history of cardiac disease.

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A nurse is caring for a client in the intensive care unit. Exhibits Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse administers an opioid analgesic to a postoperative client who also has severe obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client alone?

Correct Answer is C

Explanation

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

Correct Answer is A

Explanation

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A nurse is caring for a client in the intensive care unit. Exhibits Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

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