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.
Computerized tomography (CT) scan of the chest
Albuterol treatments by nebulizer every 4 to 6 hours
Chest x-ray
Increase oral fluids
Arterial blood gas (ABG)
Correct Answer : B,C,D,E
Choice A rationale:
A computerized tomography (CT) scan of the chest is not typically required for routine pneumonia cases unless there are complications or the pneumonia is not responding to standard treatment. CT scans provide more detailed images but are usually reserved for more complex cases.
Choice B rationale:
Albuterol treatments by nebulizer every 4 to 6 hours are appropriate for managing wheezing and bronchospasm associated with pneumonia, especially in a patient with a history of COPD. Albuterol helps open the airways, making it easier for the patient to breathe.
Choice C rationale:
A chest x-ray is a standard diagnostic tool for pneumonia. It helps assess the extent of lung involvement and monitor the progression or resolution of the infection. Repeating the chest x-ray can help evaluate the effectiveness of the treatment.
Choice D rationale:
Increasing oral fluids is essential for patients with pneumonia to help thin mucus, making it easier to expectorate. Adequate hydration also supports overall health and recovery.
Choice E rationale:
Obtaining an arterial blood gas (ABG) is important for assessing the patient’s oxygenation and acid-base status. This information is crucial for managing respiratory distress and ensuring adequate oxygen delivery.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Choice A rationale
Offering mouthwash for thorough cleansing after brushing teeth can be too harsh for clients with painful mouth ulcers caused by Candida albicans. It may cause further irritation and discomfort.
Choice B rationale
While assistive personnel can help with personal care, oral care should not be left solely to the nurse. Providing appropriate tools and guidance for the client to perform oral care is essential.
Choice C rationale
Providing a soft-bristled toothbrush is appropriate for clients with oral Candida albicans. It helps in gentle cleaning without causing additional pain or damage to the mucosa.
Choice D rationale
Wearing sterile gloves is not necessary for routine oral care. Clean gloves are sufficient unless there is a specific need for sterility, such as in surgical procedures.
Correct Answer is C
Explanation
Choice A rationale
Attaching humidification to oxygen delivery can help with comfort but is not the immediate priority in assessing the client’s respiratory status.
Choice B rationale
Coaching through using huff coughing is a useful technique for clearing secretions but should follow the assessment of the client’s oxygenation status.
Choice C rationale
Obtaining a pulse oximetry reading is the next immediate action after positioning the client upright. It provides essential information about the client’s oxygen saturation and helps guide further interventions.
Choice D rationale
Providing a nebulizer breathing treatment can help relieve symptoms but should be based on the assessment of the client’s oxygenation status.