Nokea
A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds, the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?
- A. I have a sharp pain in my chest when I take a breath.
- B. I have been coughing up foul-tasting, brown, thick sputum.
- C. I have been sweating all day.
- D. I feel hot off and on.
Correct Answer: B
Rationale: Coughing up foul-tasting, brown, thick sputum suggests a possible abscess or secondary infection, requiring attention. Choice A may indicate pleurisy, but the focus should be on the sputum. Choice C may be non-specific and could be related to the infection or fever. Choice D is non-specific and may be expected during an infection.
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What is the most effective nursing intervention to prevent atelectasis from developing in a postoperative client?
- A. Maintain adequate hydration
- B. Assist the client to turn, deep breathe, and cough
- C. Ambulate the client within 12 hours
- D. Splint the incision
Correct Answer: B
Rationale: The correct answer is to assist the client to turn, deep breathe, and cough. This intervention helps to expand the lungs and prevent atelectasis in postoperative clients. Maintaining adequate hydration is important for overall health but is not the most effective intervention for preventing atelectasis. Ambulating the client within 12 hours is beneficial for preventing complications after surgery, but it may not be as directly effective in preventing atelectasis as turning, deep breathing, and coughing. Splinting the incision is important for postoperative care, but it does not specifically address the prevention of atelectasis.
A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements by the client indicates an understanding of the dietary teaching?
- A. Eating yogurt can help decrease gas odor that I have.
- B. I should eliminate pasta from my diet so that I don't have as many loose stools.
- C. My largest meal of the day should be in the evening.
- D. Carbonated beverages can help control odor.
Correct Answer: A
Rationale: The correct answer is A. Yogurt contains probiotics which can help reduce gas and odor in colostomy patients. Choice B is incorrect because pasta is a low-fiber food that can help thicken stools, which may be beneficial for colostomy patients. Choice C is incorrect because it is generally recommended for colostomy patients to have their largest meal earlier in the day to allow for better digestion. Choice D is incorrect because carbonated beverages can actually increase gas production and worsen odor in colostomy patients.
A nurse is caring for a new mother who is breastfeeding her term newborn. The newborn weighed 3.4 kg (7.5 lb) at birth and weighs 3.3 kg (7.3 lb) on the second day of life. The mother expresses concern about the weight loss and asks the nurse about the amount of her breast milk. Which of the following responses by the nurse is appropriate?
- A. Why don't you switch to formula to ensure your baby is eating enough?
- B. It is common for new mothers to worry that they are not producing enough milk for their baby.
- C. A healthy newborn can lose 6% of his birth weight before starting to gain weight.
- D. Your newborn will need to remain in the hospital so his weight can be monitored.
Correct Answer: C
Rationale: The correct answer is C. A healthy newborn can lose up to 6% of their birth weight within the first few days of life, which is considered normal. This weight loss is usually due to fluid shifts and initial adjustments. Choices A, B, and D are incorrect. Choice A is inappropriate as switching to formula is not necessary at this point. Choice B, while acknowledging the mother's concerns, does not provide factual information about newborn weight loss. Choice D is unnecessary and may cause unnecessary stress to the mother and newborn since monitoring weight loss at home is sufficient unless there are other concerns.
A nurse is caring for four clients. The nurse should observe which of the following clients for a risk of vitamin B6 deficiency?
- A. A client who has cystic fibrosis
- B. A client who has chronic alcohol use disorder
- C. A client who takes phenytoin for a seizure disorder
- D. A client who is prescribed rifampin for tuberculosis
Correct Answer: B
Rationale: Chronic alcohol use disorder can lead to vitamin B6 deficiency due to impaired absorption and increased excretion of the vitamin. While clients with cystic fibrosis may be at risk for fat-soluble vitamin deficiencies, such as vitamins A, D, E, and K, they are not specifically at high risk for vitamin B6 deficiency. Clients taking phenytoin are at risk for folate deficiency, not vitamin B6. Clients prescribed rifampin for tuberculosis are at risk for vitamin D deficiency, not vitamin B6.
A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, the oxygen is running at 6 liters per minute, the client's color is flushed, and his respirations are 8 per minute. What should the nurse do first?
- A. Obtain a 12-lead EKG
- B. Place the client in high Fowler's position
- C. Lower the oxygen rate
- D. Take baseline vital signs
Correct Answer: C
Rationale: In a client with COPD, it is crucial to prevent carbon dioxide retention by avoiding high oxygen levels. As the client's oxygen is running at 6 liters per minute and he is showing signs of oxygen toxicity, such as flushed color and low respirations, the nurse's priority should be to lower the oxygen rate. This action helps prevent worsening the client's condition. Obtaining an EKG, placing the client in high Fowler's position, or taking baseline vital signs are important assessments but addressing the potential oxygen toxicity takes precedence in this scenario.