Nokea
A client with pneumococcal pneumonia was started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul taste and smell to the client's sputum. Which one 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: Foul smelling and tasting sputum signals a risk of a lung abscess. This puts the client in grave danger since abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for infections.
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The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test?
- A. I can't lie in one position for more than thirty minutes.'
- B. I am allergic to shrimp.'
- C. I suffer from claustrophobia.'
- D. I developed a severe headache after a spinal tap.'
Correct Answer: B
Rationale: I am allergic to shrimp.' A client undergoing myelography should be questioned carefully about allergies to iodine and iodine-containing substances such as seafood. An allergy to iodine or seafood may indicate sensitivity to the radiopaque contrast agent used in the test. An allergic reaction could even include seizures.
The client who has airborne precautions asks the nurse not to shut his door. Which response by the nurse is most appropriate?
- A. "If I open the door you will need to always wear a mask."
- B. "The door must be kept closed, but I can open the curtains."
- C. "Don't worry; I can leave the door open if it's bothering you."
- D. "I'm sorry, but I can only leave the door partially open."
Correct Answer: B
Rationale: B: Keeping the door closed contains airborne pathogens; opening curtains reduces isolation feelings. A, C, D: Open or partially open doors risk pathogen spread.
A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol?
- A. All 4 side rails up, wheels locked, bed closest to door
- B. Lower side rails up, bed facing doorway
- C. Knee-high, head slightly elevated, bed in lowest position
- D. Bed in lowest position, wheels locked, place bed against wall
Correct Answer: D
Rationale: Bed in lowest position, wheels locked, place bed against wall. Using all 4 side rails is considered a restraint and limits client autonomy unless medically necessary with an order. Lower side rails alone do not adequately prevent falls. The bed in the lowest position with wheels locked and placed against the wall minimizes fall risk while allowing the client freedom of movement.
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place client in the wheelchair for four hours each day
- B. Pad the bony prominence
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?
- A. Bruising at the operative site
- B. Elevated heart rate
- C. Decreased platelet count
- D. No bowel movement for 3 days
Correct Answer: D
Rationale: No bowel movement for 3 days. With opioid analgesics, observe for respiratory depression, sedation, and constipation. Bruising is not related to the analgesic, but could be the result of corticosteroids or previously used anticoagulants. Elevated heart rate could be the result of bronchodilators. Some antibiotics can lower platelet count.