A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) and is diagnosed with pneumonia. The client has been on a long-term regimen of methylprednisolone. Which precautions should the nurse take to prevent complications? Select all that apply.

Ensure the client receives adequate amounts of fluids

Check the client's mouth for stomatitis

Assess the client's mental status

Monitor for signs of hypokalemia

Monitor the clients blood glucose levels

Monitor the clients blood pressure for hypotension

Answer and Explanation

Correct Answer : A,B,C,D,E,F

Ensure the client receives adequate amounts of fluids: This is important to maintain hydration and thin respiratory secretions, making it easier for the client to cough and clear the airways. Check the client's mouth for stomatitis: Methylprednisolone can increase the risk of developing oral candidiasis (thrush) or stomatitis, which can cause discomfort and interfere with oral intake. Regular mouth checks can help identify these conditions early for appropriate management. Assess the client's mental status: Pneumonia, particularly in individuals with pre-existing lung disease like COPD, can lead to hypoxemia, which may affect mental status. It is important to monitor the client's mental status, as changes in cognition or confusion can be indicators of hypoxia and require prompt intervention.

Monitor for signs of hypokalemia: Methylprednisolone, like other corticosteroids, can cause electrolyte imbalances, including hypokalemia (low potassium levels). Hypokalemia can have various effects on the body, including muscle weakness and cardiac dysrhythmias. Regular monitoring of potassium levels and signs of hypokalemia is important for timely management. Monitor the client's blood glucose levels: Methylprednisolone can increase blood glucose levels, particularly in individuals with pre-existing diabetes or impaired glucose tolerance. Regular monitoring of blood glucose levels is necessary to ensure proper glycemic control and prevent hyperglycemia-related complications.

Monitor the client's blood pressure for hypotension: Corticosteroids like methylprednisolone can cause fluid retention, leading to an increase in blood pressure. However, sudden withdrawal of corticosteroids can result in adrenal insufficiency and hypotension. Close monitoring of blood pressure is necessary to identify any significant changes and adjust the medication regimen accordingly.

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Correct Answer is B

Explanation

Respiratory acidosis is a primary acid-base imbalance that occurs when there is an excess of carbon dioxide (CO2) in the body due to impaired ventilation or inadequate removal of CO2 from the lungs. In this case, Colleen's depressed ventilation, indicated by shallow and slow respirations, can lead to inadequate elimination of CO2 from her body. The excessive CO2 levels can result in an accumulation of carbonic acid (H2CO3) in the blood, leading to an increase in acidity and a decrease in pH.

The profuse bleeding from both ears indicates a potential head injury, which can lead to decreased neurological function and impaired control over the respiratory center in the brain. This can further contribute to depressed ventilation and the development of respiratory acidosis. Metabolic acidosis, characterized by a decrease in bicarbonate (HCO3-) levels or an increase in non-carbonic acids in the blood, is not the primary acid-base imbalance in this case since the scenario does not provide information indicating a primary metabolic disorder. Respiratory alkalosis, characterized by decreased levels of CO2 in the blood, leading to increased pH and alkalinity, is not the primary acid-base imbalance in this case. The depressed ventilation and associated increase in CO2 levels indicate the opposite, respiratory acidosis. Metabolic alkalosis, characterized by an increase in bicarbonate levels or a decrease in non-carbonic acids, is not the primary acid-base imbalance in this case as the scenario does not provide information indicating a primary metabolic disorder.

A. Check the patency of the NG tube. B. Place the patient in a recumbent position. C. Encourage the patient to deep breathe and consciously relax. D. Assess the patient's vital signs and circulatory status.

Correct Answer is D

Explanation

The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.

While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.

Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.

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A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) and is diagnosed with pneumonia. The client has been on a long-term regimen of methylprednisolone. Which precautions should the nurse take to prevent complications? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?

Correct Answer is D

Explanation

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