The nurse completes discharge teaching for a patient who has had a lung transplant. The nurse evaluates that the teaching has been effective if the patient makes which statement?
- A. I will make an appointment to see the doctor every year.
- B. I will stop taking the prednisone if I experience a dry cough.
- C. I will not worry if I feel a little short of breath with exercise.
- D. I will call the health care provider right away if I develop a fever.
Correct Answer: D
Rationale: The correct answer is, 'I will call the health care provider right away if I develop a fever.' It is crucial for patients who have undergone a lung transplant to be vigilant about any signs of infection or rejection. A low-grade fever can be an early indicator of such complications, requiring immediate medical attention. While annual follow-up visits are necessary, they are not sufficient for monitoring acute changes in health post-transplant. Stopping prednisone abruptly can lead to rejection and should only be done under healthcare provider guidance. Feeling short of breath with exercise should be reported as it can indicate potential issues. Recognizing and addressing symptoms promptly is key to successful post-transplant care, and in this case, calling the healthcare provider immediately for a fever is the most appropriate action.
You may also like to solve these questions
The nurse prepares a patient with a left-sided pleural effusion for a thoracentesis. How should the nurse position the patient?
- A. Supine with the head of the bed elevated 30 degrees
- B. In a high-Fowler's position with the left arm extended
- C. On the right side with the left arm extended above the head
- D. Sitting upright with the arms supported on an overbed table
Correct Answer: D
Rationale: The correct position for a patient with a left-sided pleural effusion undergoing thoracentesis is sitting upright with the arms supported on an overbed table. This position helps increase lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space making access to the pleural space easier. Placing the patient supine, in a high-Fowler's position, or on the right side with the left arm extended above the head could increase the work of breathing for the patient and complicate the thoracentesis procedure for the healthcare provider.
A patient has just been admitted with probable bacterial pneumonia and sepsis. Which order should the nurse implement first?
- A. Performing a chest x-ray via stretcher
- B. Obtaining blood cultures from two sites
- C. Administering Ciprofloxacin (Cipro) 400 mg IV
- D. Inserting an Acetaminophen (Tylenol) rectal suppository
Correct Answer: B
Rationale: In a patient with probable bacterial pneumonia and sepsis, the priority intervention is to obtain blood cultures from two sites before initiating antibiotic therapy. This is crucial to identify the causative organism and guide appropriate antibiotic treatment. Administering antibiotics without obtaining cultures first can interfere with accurate results. Performing a chest x-ray and administering acetaminophen can be done after obtaining blood cultures as they are important but not as urgent as identifying the causative organism in sepsis.
A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?
- A. Do not let this prescription run out.
- B. The medication may cause gingival hyperplasia.
- C. Periodic serum drug levels are needed.
- D. Watch for excessive facial hair growth.
Correct Answer: A
Rationale: The correct teaching for the child and parents when a child is prescribed baclofen via an intrathecal pump is to not let the prescription run out. Abrupt discontinuation of intrathecal baclofen can lead to severe effects like high fever, altered mental status, and rebound spasticity and muscle rigidity. It is crucial for the parents to ensure there is always an adequate supply of this medication to prevent these adverse effects. Choices B and D are incorrect because gingival hyperplasia and hirsutism are side effects associated with phenytoin (Dilantin), not baclofen. Choice C is incorrect as serum drug levels are not typically monitored for intrathecal medications.
While auscultating a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?
- A. Inspiratory crackles at the bases
- B. Expiratory wheezes in both lungs
- C. Abnormal lung sounds in the apices of both lungs
- D. Pleural friction rub in the right and left lower lobes
Correct Answer: A
Rationale: The correct answer is 'Inspiratory crackles at the bases.' Crackles are low-pitched, bubbling sounds typically heard during inspiration, which aligns with the nurse's finding. Expiratory wheezes are high-pitched sounds and are not consistent with the described auscultation findings. The lower third of both lungs refers to the bases, not the apices, so option C is incorrect. Pleural friction rubs are grating sounds heard during both inspiration and expiration, unlike the described finding of only hearing the sounds during inhalation in the lower third of both lungs.
A nurse is caring for a patient with peripheral vascular disease (PVD). The patient
complains of burning and tingling of the hands and feet and cannot tolerate touch of any
kind. Which of the following is the most likely explanation for these symptoms?
- A. Inadequate tissue perfusion leading to nerve damage.
- B. Fluid overload leading to compression of nerve tissue.
- C. Sensation distortion due to psychiatric disturbance.
- D. Inflammation of the skin on the hands and feet.
Correct Answer: A
Rationale: Patients with the peripheral vascular disease often sustain nerve damage as a result of
inadequate tissue perfusion. Ischemic rest pain is more worrisome; it refers to pain in the
extremity that is due to a combination of PVD and inadequate perfusion. Ischemic rest
pain often is exacerbated by poor cardiac output. The condition is often partially or fully
relieved by placing the extremity in a dependent position, so that perfusion is enhanced by
the effects of gravity.