A nurse is caring for a client who has pneumonia.
Exhibit 1
Medication Administration Record
Day 1, 1500:
Cefazolin 500 mg every 12 hr IV
Dexamethasone 15 mg every 6 hr IV
Day 3, 1200:
Discontinue dexamethasone 15 mg every 6 hr IV Prednisone 40 mg PO daily
Day 4, 1500:
Discontinue cefazolin 500 mg every 12 hr IV
The nurse is providing discharge teaching for the client and their caregiver. Which of the following information should the nurse include? Select all that apply.
Antibiotic medication can be taken with or without food,
The steroid dose will decrease each day.
Adjust the oxygen flow rate as needed to ease breathing.
Antibiotic therapy should be taken for 10 days.
Store the oxygen cylinder wrench with the oxygen tank.
Steroid medication should be taken in the morning.
Ensure the oxygen delivery system is at least 8 feet from any heat source.
Correct Answer : B,C,F,G
A. Antibiotic medication can be taken with or without food.
This statement is not specifically relevant to the discharge teaching for this client with pneumonia. However, the nurse should provide specific instructions regarding the administration of the antibiotic (cefazolin), which is typically administered intravenously in a healthcare setting and may not be taken orally at home.
B. The steroid dose will decrease each day.
Explanation: This information ensures that the client and caregiver are aware of the tapering regimen for the steroid medication (prednisone), which is essential to prevent adrenal insufficiency and other potential adverse effects associated with abrupt discontinuation.
C. Adjust the oxygen flow rate as needed to ease breathing.
Explanation: This information educates the client and caregiver on how to manage oxygen therapy effectively at home, ensuring optimal oxygen delivery and respiratory support.
D. Antibiotic therapy should be taken for 10 days.
The duration of antibiotic therapy for pneumonia depends on the specific antibiotic prescribed and the severity of the infection. The nurse should provide clear instructions based on the healthcare provider's prescription and guidelines.
E. Store the oxygen cylinder wrench with the oxygen tank.
While storing the oxygen cylinder wrench with the oxygen tank is a good practice, it is not directly related to discharge teaching for this client with pneumonia.
F. Steroid medication should be taken in the morning.
Explanation: Taking steroid medication (prednisone) in the morning helps minimize disruption of the body's natural cortisol rhythm and reduces the risk of insomnia associated with steroid use.
G. Ensure the oxygen delivery system is at least 8 feet from any heat source.
Explanation: Proper storage and placement of the oxygen delivery system reduce the risk of fire hazards associated with oxygen therapy, promoting safety within the home environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Swing-through gait:
The swing-through gait is a more advanced gait pattern used by clients with significant lower extremity weakness or paralysis. It involves swinging both crutches forward simultaneously, followed by swinging both legs forward past the crutches. This gait is not appropriate for a client who can only bear weight on one leg.
B. Three-point gait:
The three-point gait is typically used when one lower extremity is completely non-weight-bearing. It involves advancing both crutches and then swinging the affected leg through to meet the crutches. Since the client in this scenario can bear weight on one leg, the three-point gait is the most appropriate choice.
C. Four-point alternating gait
Four-point alternating gait
The four-point alternating gait involves a sequence of movements where each crutch and each leg move alternately. The sequence is as follows:
- Move the right crutch forward(injured side).
- Move the left foot forward(non-injured side).
- Move the left crutch forward(non-injured side).
- Move the right foot forward(injured side). This gait offers stability and control but requires more effort and coordination.
D. Two-point alternating gait:
The two-point alternating gait involves moving one crutch and the opposite lower extremity forward simultaneously, followed by moving the other crutch and the opposite lower extremity forward. This gait pattern is typically used by clients who have good balance and strength in both lower extremities. It may not provide enough stability and support for a client who can only bear weight on one leg.
Correct Answer is ["A","B","D"]
Explanation
A. Ensure that the client's bed is in the lowest position.
Keeping the bed in the lowest position helps prevent injury if the client tries to get out of bed, especially when restrained.
B. Assess skin temperature and color before applying the restraints.
This action ensures proper circulation and skin integrity while the restraints are in use. It helps prevent skin breakdown and injury.
C. Attach the client's restraints to the bed rail.
Attaching restraints to the bed rail is not considered a best practice as it can increase the risk of injury to the client. Restraints should be secured to the bed frame or another stable part of the bed to minimize the risk of harm.
D. Pad bony prominences before applying the restraints.
Padding bony prominences such as elbows and wrists helps prevent pressure ulcers and discomfort caused by the restraints.
E. Secure restraints to allow three fingers to slide under the restraints.
Restraints should be secured to allow only two fingers to slide under the restraints to ensure they are not too loose or too tight.
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