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An adult client is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates to the assistive personnel (AP) and discusses how to assist the client. Which instruction should the nurse provide?

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

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

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?

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.

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?

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the nurse that they did not notice any reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

A client has a nasogastric (NG) tube placed during abdominal surgery. During postoperative convalescence, which arterial blood gas values are consistent with metabolic alkalosis?

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?