Take full exam for free

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.

A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94%, a weak cough effort, and is using accessory muscles to breathe. Which intervention should the nurse implement first?

Exhibit 1: History and Physical

The client is a 51-year-old male admitted to the medical floor with a diagnosis of pneumonia. He reports a 3-day history of productive cough, shortness of breath, and fever. He also mentions increased fatigue and weakness over the last week. The client has a history of hypertension, which is controlled with enalapril 10 mg daily. His surgical history includes adenoidectomy at age 5 and surgical repair of a fractured femur at age 20. The client takes a multivitamin daily and has no known allergies. He is a non-smoker and reports occasional alcohol use.

Exhibit 2: Nurse's Notes (0800)

At 0800, the client was alert but appeared fatigued and short of breath. His oxygen saturation was 89% on room air, and he was placed on supplemental oxygen at 10 L/min via nasal cannula, which improved his saturation to 94%. The client stated, “I feel tired and weak, and it’s hard to breathe.” His skin was warm to the touch, and he had a productive cough with thick, yellow sputum. He reported a headache and body aches, rating his pain as 4/10. The client denied chest pain but reported feeling feverish throughout the night. His capillary refill was less than 3 seconds, and lung sounds were diminished with crackles heard bilaterally.

Exhibit 3: Vital Signs

• Time: 0800
• Temperature: 101.2°F (38.4°C)
• Pulse: 112 beats per minute
• Respiratory Rate: 28 breaths per minute
• Blood Pressure: 150/92 mmHg
• Oxygen Saturation: 89% on room air, 94% on 10 L/min nasal cannula

Exhibit 4: Physical Examination Results

Upon physical examination, the client appeared ill and was in mild respiratory distress, with shallow and rapid breathing. His skin was warm and flushed, and he was diaphoretic. Lung auscultation revealed bilateral crackles in the lower lobes, more pronounced on the right side. There were no wheezes or rhonchi noted. His heart sounds were regular, but tachycardia was present. The client’s abdomen was soft and non-tender with normal bowel sounds. No edema was noted in the extremities, and there were no visible rashes or skin abnormalities. The client’s capillary refill was normal, and neurological assessment showed no focal deficits.

Exhibit 5: Provider's Prescriptions

1. Admit to the medical floor
2. Vital signs every 4 hours
3. Continuous pulse oximetry
4. Supplemental oxygen 10 L/min via nasal cannula
5. Enalapril 10 mg PO every morning
6. Ibuprofen 400 mg PO every 4 to 6 hours PRN for temperature greater than 100.5°F (38.0°C)
7. Send blood for complete blood count and electrolytes
8. Chest X-ray now

Question: Which of the following provider's prescriptions would the nurse question? Select all that apply.

A teenage client is admitted to the emergency department following a bee sting. The client arrives with a body rash and 30 of 40 breaths per minute and a blood pressure of 90/52 mm Hg. The client is exhibiting clinical manifestations of which type of immune reaction?

Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?

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?

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

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

A client diagnosed with chronic obstructive pulmonary disease (COPD) is given a new prescription for tiotropium via an inhalation device. Which statement indicates the client understands the instructions for using this medication?

A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?