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The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

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

The antitubercular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness of this medication, which outcome can the nurse expect this client to exhibit?

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath and a productive cough with thickened, tenacious mucus. The client reports difficulty walking up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

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.

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

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 planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

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?

An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to “speak up so that she can hear.”. Which action is best for the nurse to take?