An older adult with pneumonia and an exacerbation of chronic obstructive pulmonary disease (COPD) was intubated for 14 days and was sucessfully extubated yesterday. Currently, the client has a weak cough and poor appetite. Which intervention(s) should the nurse implement? Select all that apply.

Encourage activity as tolerated.

Assess ability to swallow solids and liquids.

Assist client with active range of motion.

Reinforce deep breathing exercises.

Obtain dietary consult for meal supplements.

Answer and Explanation

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

Rationale:
A. Encourage activity as tolerated: Gradual mobilization supports respiratory function, circulation, and muscle strength after prolonged intubation. Activity also helps reduce the risk of complications like atelectasis and deep vein thrombosis.

B. Assess ability to swallow solids and liquids: After extended intubation, clients are at risk for dysphagia, which can lead to aspiration pneumonia. A swallowing assessment is necessary to ensure safety before resuming a regular oral diet.

C. Assist client with active range of motion: Prolonged immobility in the ICU often leads to deconditioning and muscle weakness. Assisting with range of motion exercises promotes circulation, prevents contractures, and maintains joint flexibility.

D. Reinforce deep breathing exercises: Deep breathing promotes alveolar expansion, improves oxygenation, and prevents postoperative complications such as pneumonia or atelectasis, which are particularly concerning after extubation and in clients with COPD.

E. Obtain dietary consult for meal supplements: Poor appetite post-extubation can contribute to malnutrition and delayed recovery. A dietary consult ensures the client receives adequate caloric and protein intake through appropriate supplements.

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Correct Answer is C

Explanation

Rationale:
A. Hold the skin fold throughout the injection: Pinching the skin may be helpful to avoid intramuscular injection, especially in thin clients, but it's not required throughout the entire injection process. It is not the most critical technique compared to air bubble retention.

B. Insert the needle at a 90 degree angle: A 90-degree angle is appropriate for clients with sufficient subcutaneous tissue, but in thinner clients a 45-degree angle may be safer. The angle depends on the client’s body habitus and is not universally required.

C. Retain the air bubble in the syringe barrel: The air bubble helps ensure that the full dose is delivered and prevents medication from tracking through subcutaneous tissue, which could cause bruising. It should not be expelled before administering enoxaparin.

D. Massage the area after injection: Massaging the site can increase the risk of bruising and tissue irritation with anticoagulants like enoxaparin. Gentle pressure may be applied if needed, but the site should not be massaged.

A. Shaking that changes the child's handwriting legibility. B. Bruises on both knees after the weekend. C. Sunburn with blisters on the face, arms, and hands. D. Refuses to complete written homework assignments. E. Thirst and frequent requests for bathroom breaks.

Correct Answer is ["A","C","E"]

Explanation

Rationale:

A. Shaking that changes the child's handwriting legibility: Sudden onset of tremors affecting fine motor skills may indicate a neurological issue, such as a seizure disorder or early signs of a neurological condition, and requires prompt evaluation by the school nurse.

B. Bruises on both knees after the weekend: Bruises on the knees in children are often consistent with normal play and activity. Unless the bruises are unusual in pattern or location (e.g., upper arms, back), they typically do not require immediate referral.

C. Sunburn with blisters on the face, arms, and hands: Blistering sunburns can lead to dehydration, pain, and secondary infection. Facial involvement and blistering elevate the severity and warrant assessment and possible treatment recommendations.

D. Refuses to complete written homework assignments: While this behavior might suggest learning or behavioral challenges, it is not an urgent health issue requiring immediate referral. Teachers should monitor and possibly refer through academic support services, not directly to the nurse.

E. Thirst and frequent requests for bathroom breaks: These symptoms could be early signs of undiagnosed diabetes mellitus and warrant immediate attention from the school nurse to initiate further assessment and notify the child’s guardian.

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An older adult with pneumonia and an exacerbation of chronic obstructive pulmonary disease (COPD) was intubated for 14 days and was sucessfully extubated yesterday. Currently, the client has a weak cough and poor appetite. Which intervention(s) should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer enoxaparin 30 mg subcutaneously using a pre-filled syringe containing 30 mg in 0.3 mL. Which action should the nurse implement?

Correct Answer is C

Explanation

The school nurse is preparing a presentation for elementary school teachers to inform them when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

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