Nokea
An older adult is admitted with severe pneumonia. Which of the following measures should the nurse include in the plan of care immediately after admission? Select all that apply.
- A. Encourage the client to drink 2 L of fluid daily.
- B. Administer antipyretics as ordered.
- C. Administer antibiotics as ordered.
- D. Administer mucolytics as ordered.
- E. Ambulate three times a day.
- F. Eat three large meals a day.
Correct Answer: A,B,C,D
Rationale: Fluids hydrate and thin secretions, antipyretics control fever, antibiotics treat infection, and mucolytics aid mucus clearance in pneumonia. Ambulation and large meals may be inappropriate initially due to fatigue.
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A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client's greatest risk factors for osteoporosis?
- A. History of menopause at age 50
- B. Taking high doses of steroids for arthritis for many years
- C. Maintaining an inactive lifestyle for the past 10 years
- D. Drinking 2 glasses of red wine each day for the past 30 years
Correct Answer: B
Rationale: Taking high doses of steroids for arthritis for many years. The use of steroids, especially at high doses over time, increases the risk for osteoporosis. The other options also predispose to osteoporosis, as do low bone mass, poor calcium absorption and moderate to high alcohol ingestion. Long-term steroid treatment is the most significant risk factor, however.
The physician's orders include warm compresses to the left leg three times a day for treatment of an open wound. Which action is appropriate when carrying out these orders?
- A. Use medical aseptic technique.
- B. Leave the wet compress open to the air.
- C. Place both a dry covering and waterproof material over the compress.
- D. Remove the compress after five minutes.
Correct Answer: C
Rationale: A dry covering and waterproof material over the compress maintain warmth and prevent contamination while keeping the surrounding area dry. Aseptic technique is needed for open wounds, open-air compresses lose heat, and five minutes is too short.
In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the nurse must
- A. Assess the brachial pulses
- B. Breathe once every 5 compressions
- C. Use both hands to apply chest pressure
- D. Compress 80-90 times per minute
Correct Answer: B
Rationale: Breathe once every 5 compressions. For a 5 year-old, the nurse should give 1 breath for every 5 compressions.
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
- A. Risk for dehydration
- B. Ineffective airway clearance
- C. Altered nutrition
- D. Risk for injury
Correct Answer: B
Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.
The nurse in a long-term care facility wants to help a resident become continent of stools. Which is likely to be most helpful when planning care for the resident? Select all that apply.
- A. Take the resident to the toilet after meals
- B. Limit the amount of fruits and vegetables the client consumes
- C. Encourage the resident to drink fluids
- D. Take the resident for a walk around the unit several times a day
- E. Ask the resident to list his/her favorite foods
- F. Discourage snacking between meals
Correct Answer: A,C,D
Rationale: Toileting after meals leverages the gastrocolic reflex, fluids soften stool, and walking stimulates peristalsis, all promoting continence. Limiting fiber, listing foods, or discouraging snacking are less effective or counterproductive.