A nurse is caring for a client who has asthma and is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?
Hypertension
Polyuria
Oral candidiasis
Hypoglycemia
The Correct Answer is C
A. Hypertension: While systemic corticosteroids can lead to hypertension, fluticasone, when inhaled, typically has minimal systemic effects.
B. Polyuria: Polyuria is more associated with systemic corticosteroids or diabetes management, not with inhaled fluticasone.
C. Oral candidiasis: Inhaled corticosteroids like fluticasone can lead to oral thrush, so rinsing the mouth after use is advised to prevent this.
D. Hypoglycemia: Corticosteroids typically cause hyperglycemia rather than hypoglycemia.
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Correct Answer is ["A","C","D"]
Explanation
A. Perform passive range of motion exercises. Passive range of motion exercises help maintain circulation and reduce venous stasis, which is crucial for preventing pulmonary embolism in clients who are immobile.
B. Place pillows under the client's knees when in bed. Placing pillows under the knees can actually promote venous stasis and increase the risk of a pulmonary embolism. It is better to keep the legs flat to encourage circulation.
C. Assess legs for redness. Regular assessment of the legs for redness, swelling, or warmth helps in the early detection of deep vein thrombosis (DVT), which can lead to pulmonary embolism if not addressed.
D. Apply elastic compression stockings. Elastic compression stockings promote venous return from the legs to the heart and help prevent DVT, thereby reducing the risk of pulmonary embolism.
E. Massage the calves every shift. Massaging the calves can dislodge a thrombus and potentially lead to a pulmonary embolism. Instead, interventions should focus on preventing thrombus formation.
Correct Answer is C
Explanation
A. Friction rub: A friction rub is usually associated with pleuritis, not atelectasis. Atelectasis involves the collapse of alveoli and does not produce this sound.
B. Decreasing respiratory rate: Atelectasis generally leads to an increased respiratory rate as the body compensates for decreased oxygenation.
C. Increasing dyspnea: Increasing dyspnea is common in atelectasis as collapsed alveoli reduce oxygen exchange, leading to shortness of breath and increased respiratory effort.
D. Facial flushing: Facial flushing is not typically associated with atelectasis; instead, atelectasis leads to signs of respiratory distress, such as dyspnea and possibly cyanosis.