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A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

To assess the quality of an adult client’s pain, which approach should the nurse use?

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client’s respiratory acidosis?

A client with emphysema is reporting difficulty in breathing and exhibiting audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

A nurse is caring for a 76-year-old male client in the medical unit

History and Physical

The client is a 76-year-old male with a history of chronic obstructive pulmonary disease (COPD) and hypertension. He presented to the emergency department with a 3-day history of productive cough, fever, and shortness of breath. He has a 40-pack-year smoking history and lives alone. He denies recent travel or sick contacts.

Nurses’ Notes

Day 1, 1800: The client was admitted to the medical unit with suspected pneumonia. Crackles were auscultated bilaterally in the lower lung fields, and breath sounds were diminished. A saline infusion was initiated at 50 mL/hour. Vancomycin IV piggyback (IVPB) was started. Sputum and blood cultures were obtained and sent to the lab.

Diagnostic Results

Day 2: Sputum culture positive for pneumococcus. Chest x-ray showed focal consolidation in the bilateral lower lobes, suggestive of pneumonia.

Vital Signs

• Temperature: 38.5°C
• Heart Rate: 110 bpm
• Respiratory Rate: 24 breaths/min
• Blood Pressure: 150/90 mmHg
• Oxygen Saturation: 88% on room air

Physical Examination Results

On physical examination, the client appeared in moderate respiratory distress. He had crackles bilaterally in the lower lung fields and diminished breath sounds throughout. His skin was warm and diaphoretic. He was using accessory muscles to breathe and had a productive cough with greenish sputum.

Provider’s Prescriptions

• Continue saline infusion at 50 mL/hour
• Discontinue vancomycin
• Start ceftriaxone 1g IV every 24 hours
• Albuterol treatments by nebulizer every 4 to 6 hours
• Increase oral fluids
• Obtain arterial blood gas (ABG)

Imaging Studies

Chest x-ray showed focal consolidation in the bilateral lower lobes, suggestive of pneumonia.

Question: Which of the following does the nurse anticipate the healthcare provider to prescribe during morning rounds? Select 4 findings.

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?

A client with newly diagnosed Crohn’s disease asks the nurse about dietary restrictions. How should the nurse respond?

A nurse is caring for a 51-year-old male client with pneumonia in the hospital. The client has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4 and surgical repair of a fractured tibia at age 20.

History and Physical

The client is a 51-year-old male with pneumonia. He has a history of hypertension and takes enalapril and a multivitamin daily. His surgical history includes adenoid removal at age 4 and surgical repair of a fractured tibia at age 20.

Nurses’ Notes

The client is alert and oriented but appears fatigued. He reports shortness of breath and a productive cough with greenish sputum. The client has been receiving oxygen therapy via nasal cannula at 2 L/min. He has been compliant with his medication regimen and reports no recent changes in his health status. The client denies any chest pain but mentions occasional wheezing.

Diagnostic Results

Chest X-ray: Consolidation noted in the right middle and lower lobe consistent with pneumonia.

Vital Signs

• Temperature: 38.5°C (101.3°F)
• Heart Rate: 98 bpm
• Respiratory Rate: 24 breaths per minute
• Blood Pressure: 145/90 mmHg
• Oxygen Saturation: 92% on 2 L/min of oxygen via nasal cannula

Physical Examination Results

The client appears fatigued and is using accessory muscles to breathe. Lung auscultation reveals crackles in the right middle and lower lobes. There is no peripheral edema, and the client’s skin is warm and dry. The client has a productive cough with greenish sputum. He is alert and oriented but appears anxious.

Provider’s Prescriptions

• Continue enalapril 10 mg daily
• Acetaminophen 500 mg every 6 hours as needed for fever
• Increase oxygen to 3 L/min via nasal cannula if oxygen saturation drops below 90%
• Administer albuterol nebulizer treatment every 4 hours as needed for wheezing
• Encourage deep breathing and coughing exercises every hour

Question: Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.