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On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
- A. Reorient to day and time frequently.
- B. Apply soft wrist restraints bilaterally.
- C. Administer a PRN dose of lorazepam.
- D. Turn the television on for distraction.
- E. Present a calm, supportive demeanor.
Correct Answer: A,C,E
Rationale: Reorienting to time, administering lorazepam, and maintaining a calm demeanor address anxiety and hallucinations, reducing distress without increasing stimulation or using restraints unnecessarily.
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A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?
- A. Begin a weight loss program.
- B. Drink 1 to 2 glasses of wine at bedtime.
- C. Take sedatives prior to sleep.
- D. Sleep with the head of the bed flat.
Correct Answer: A
Rationale: Weight loss can reduce fat deposits around the neck and throat, improving airflow and decreasing the severity of OSA, making it an effective alternative or complementary strategy to CPAP.
A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a feel itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?
- A. Swab the throat for a rapid strep test.
- B. Provide a mask for the client to wear.
- C. Instruct client to stop taking the antibiotics.
- D. Apply a hypoallergenic cream to the rash.
Correct Answer: C
Rationale: Symptoms like rash, wheezing, and tachycardia suggest an allergic reaction to antibiotics, requiring immediate cessation to prevent progression to severe reactions like anaphylaxis.
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use incentive spirometer.
- B. Monitor urinary stream for decrease in output.
- C. Report when hematuria becomes pink tinged.
- D. Restrict physical activities.
Correct Answer: B
Rationale: Monitoring urinary stream for decreased output post-TUNA is essential to identify potential complications such as urinary retention, infection, or bleeding, ensuring timely intervention.
Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?
- A. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.
- B. Report the COVID-19 result to the local health department according to CDC guidelines.
- C. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus.
- D. Explain to the client to inform others that they may have been potentially exposed in the last 14 days.
Correct Answer: A
Rationale: Isolating the client immediately prevents potential COVID-19 transmission, given the suggestive symptoms, and is the priority action before reporting, educating, or contact tracing.
An adult client, a smoker, has had chronic obstructive pulmonary disease (COPD) for twelve years. When conducting discharge teaching, what should the nurse advise the client to avoid in order to prevent exacerbation of COPD?
- A. Exposure to persons with pneumonia or chickenpox.
- B. Excessive physical exertion and respiratory tract infections.
- C. Overdose of albuterol and alcohol consumption.
- D. Excessive bedrest and lack of exercise.
Correct Answer: B
Rationale: Excessive physical exertion and respiratory infections are primary triggers for COPD exacerbation, increasing oxygen demand and causing airway inflammation, which the client should avoid.