A nurse is caring for a client who has pneumonia.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Clostridium difficile infection is likely because the client has pneumonia and is receiving ceftriaxone, an antibiotic known to disrupt gut flora and cause opportunistic infections like C. difficile. The presence of frequent, liquid, foul-smelling stools further supports this diagnosis.
Myocardial infarction is unlikely because while the client has chest pain, it is pleuritic and related to inspiration rather than the typical crushing, non-pleuritic chest pain seen in an MI. There is no mention of radiating pain, diaphoresis, or hemodynamic instability.
Pulmonary edema is unlikely since it typically presents with dyspnea, crackles throughout the lung fields, pink frothy sputum, and signs of fluid overload such as peripheral edema and weight gain. The client’s symptoms do not align with this condition.
Pulmonary embolism is also unlikely, as it presents with sudden-onset dyspnea, pleuritic chest pain, tachycardia, and often calf swelling or a history of deep vein thrombosis. The client lacks the risk factors and clinical signs of PE.
Placing the client on contact precautions is necessary because C. difficile is highly contagious and spreads through the fecal-oral route. Gloves and gowns should be used to prevent transmission.
Obtaining a stool culture is necessary to confirm the presence of C. difficile toxins in the stool, which is essential for accurate diagnosis and treatment.
Requesting a prescription for an anticoagulant is not necessary because the client does not show any signs of thromboembolic disease such as deep vein thrombosis or pulmonary embolism. Anticoagulation could increase the risk of bleeding in the gastrointestinal tract, which would worsen the diarrhea.
Requesting a prescription for a diuretic is not needed because the client is more likely to be dehydrated due to diarrhea. Diuretics would exacerbate fluid loss and electrolyte imbalances.
Restricting fluids is not appropriate because dehydration is a major concern with C. difficile infection. Instead, fluid intake should be encouraged to prevent complications from excessive fluid loss.
Level of consciousness should be monitored because severe dehydration and electrolyte imbalances can lead to confusion, weakness, and altered mental status. While altered mental status can occur with severe dehydration or sepsis, it is not the primary concern at this stage.
Potassium level should be monitored because diarrhea can cause significant potassium loss, leading to hypokalemia, which can result in muscle weakness, cardiac arrhythmias, and fatigue.
Urine output is not the most specific parameter for monitoring C. difficile infection. While dehydration is a concern, tracking electrolyte levels and neurological status is more critical.
Calf swelling is not relevant since the client does not have signs or risk factors for deep vein thrombosis or pulmonary embolism.
Weight: C. difficile infection can cause significant fluid loss due to persistent diarrhea, leading to dehydration and weight loss. Tracking daily weight helps assess hydration status and the effectiveness of fluid replacement therapy.

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Correct Answer is B

Explanation

A. Supportive feedback: This term refers to positive, constructive input that aims to help a colleague improve their practice or decision-making. Nurse Taylor's behavior does not reflect supportive feedback; rather, it is negative and undermining, contributing to a hostile work environment.
B. Lateral violence: This term describes aggressive or bullying behavior exhibited by colleagues at the same hierarchical level. Nurse Taylor's sarcastic remarks and belittling comments toward Nurse Jordan are clear examples of lateral violence, as they create a toxic atmosphere and negatively impact team dynamics. This behavior can lead to increased stress and decreased morale among team members.
C. Workplace violence: While Nurse Taylor's behavior can be considered a form of workplace violence in a broader sense, it is more specifically classified as lateral violence. Workplace violence generally encompasses physical threats or harm, while lateral violence focuses on verbal and emotional abuse among coworkers.
D. Constructive criticism: Constructive criticism involves providing feedback aimed at improving performance while maintaining respect and professionalism. Nurse Taylor's sarcastic remarks do not meet this definition, as they are not aimed at helping Nurse Jordan but rather serve to belittle and undermine her. Therefore, this behavior is not constructive and instead falls into the category of lateral violence.

Correct Answer is []

Explanation

Assess for subcutaneous emphysema: Assessing for subcutaneous emphysema is crucial because it can indicate that air is escaping into the subcutaneous tissue, often resulting from a significant air leak. Early detection of subcutaneous emphysema allows for timely intervention, which is essential to manage the complication effectively and prevent further respiratory compromise.
Check the drainage system and tubing: Checking the drainage system and tubing is important to ensure that the chest tube and drainage system are functioning correctly. This includes identifying any kinks, disconnections, or leaks in the tubing that could contribute to the air leak. Ensuring the integrity of the drainage system is vital for effective management of the client’s respiratory condition and for restoring proper lung expansion.
Obtain blood cultures: This action is not indicated in this scenario unless there are signs of infection. The client’s symptoms do not suggest an infection requiring cultures at this time. Blood cultures would be more appropriate if there were signs of systemic infection, such as fever or elevated white blood cell count.
Administer prescribed blood products: This action is also not appropriate unless there is evidence of significant bleeding or anemia. The client’s hemoglobin levels are within normal limits, so this intervention is not necessary.
Observe surgical dressing: While important for monitoring the integrity of the surgical site, this action is not the priority when assessing for an air leak. Observing the dressing can help identify signs of drainage or infection but should follow the assessment for subcutaneous emphysema and the examination of the drainage system.
Respiratory status: Monitoring the client's respiratory status is crucial for assessing lung function and detecting any changes in breathing patterns, oxygen saturation, or the presence of respiratory distress. Given the client's recent thoracotomy, careful observation can help identify complications early.
Chest tube drainage: Assessing chest tube drainage is important to monitor the amount and type of fluid draining from the chest, as well as to identify any changes that may indicate bleeding or other complications. The 50 mL of sanguineous drainage noted since 0700 should be tracked to ensure it remains within acceptable limits and does not indicate excessive bleeding.
Client's ability to perform lung expansion exercises: While important for overall respiratory health, monitoring the client’s ability to perform lung expansion exercises is not as critical in the context of an acute air leak. However, encouraging lung expansion exercises can help prevent complications such as atelectasis.
Sputum: Monitoring sputum can provide information about respiratory status and potential infections. In this case, assessing sputum may be relevant but is secondary to monitoring respiratory status and chest tube drainage.
Blood pressure: Blood pressure is important to monitor but is not the primary focus in the context of chest tube management and respiratory issues. Monitoring blood pressure can provide information about the client’s overall hemodynamic stability but is not directly related to assessing the air leak.
Bleeding: While the client has some sanguineous drainage, the amount (50 mL) is not excessive, and hemoglobin levels are within normal limits. There are no signs of significant hemorrhage, making bleeding a less likely primary condition.
Pulmonary edema: Pulmonary edema typically presents with symptoms such as dyspnea, cough with frothy sputum, and hypoxia. The client's symptoms and findings do not support a diagnosis of pulmonary edema, which is more commonly associated with heart failure.
Pneumonia: While pneumonia can present with respiratory distress and abnormal lung sounds, the absence of fever and the clear sputum do not strongly indicate this condition in the current scenario. The findings are more consistent with an air leak.
Air leak: The presence of tidaling in the water seal chamber along with continuous bubbling in the chest tube drainage system suggests an air leak. Continuous bubbling indicates that air is escaping into the pleural space, which can compromise lung expansion and lead to respiratory complications. This situation necessitates immediate attention to prevent further respiratory distress.

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Correct Answer is B

Explanation

Correct Answer is []

Explanation

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