PT 4

45問 • 1年前

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the home health nurse is educating a 60-year-old patient with emphysema with a nutritional deficit. which instructions should the nurse include in the teaching plan to address this problem? (select all that apply.)

rest before eating., avoiding gas-producing foods., eat four to six small meals instead of three large meals., take small bites and chew slowly.

the nurse is caring for a patient on a mechanical ventilator that it is set on assist- control mode. which statement(s) accurately describe this function? (select all that apply.)

the ventilator delivers a set tidal volume., the ventilator delivers a set number of breaths if, the patient's rate falls.

the nurse is preparing a presentation that highlights the benefits of annual influenza vaccination. the nurse correctly targets which groups? (select all that apply.)

diabetics who are over 50 years old., home health aides., cnas who work in long- term care facilities., pregnant women.

place the events of an asthma attack in proper sequence.

mast cell-mediated inflammatory response in bronchi, mucosal edema, mucus production, plugging of small airways

Which intervention should be included on the care plan for the patient at risk for aspiration pneumonia?

Keep suction equipment at the bedside

A patient with a penetrating wound to the chest presents to the emergency department. Which type of dressing does the nurse prepare to apply?

Vented

The patient with acute respiratory distress syndrome (ARDS) is in the intensive care unit. Which position is the most appropriate for the patient to improve oxygenation?

prone

The nurse is assessing the patient with a pneumothorax. Which symptom indicates the development of a mediastinal shift?

Deviated trachea

A patient who had knee replacement surgery is admitted to the medical-surgical floor postoperatively. Which intervention to prevent embolus does the nurse expect to see on the care plan?

Active range-of-motion on the affected extremity

The patient is on heparin for a pulmonary embolus. Which lab result does the nurse expect to monitor?

Activated partial thromboplastin time (aPTT)

Which influenza strains does the influenza vaccine protect against? (Select all that apply.)

Influenza A, Influenza B

Which information should be included in the teaching plan for a patient with pneumonia? (Select all that apply.)

Avoid people with colds., Gradually increase activity., Complete any prescribed drugs., Maintain good nutrition and rest.

What is influenza virus?

contagious respiratory illness caused by influenza viruses.

What are the 3 types of influenza viruses called:

Influenza A: Most severe and responsible for pandemics (e.g., H1N1). Can infect humans and animals., Influenza B: Milder than A, affects only humans, and is responsible for seasonal flu outbreaks., Influenza C: Least common, usually causes mild respiratory illness without epidemics.

What cause influenza virus

Orthomyxoviridae family. It spreads through:, Airborne droplets (sneezing, coughing), Direct contact (touching contaminated surfaces), Close contact (crowded places, schools, hospitals)

What's the risk factors of influenza virus?

Age (young children, elderly), Weakened immune system (HIV, cancer, organ transplant), Chronic illnesses (asthma, diabetes, heart disease), Pregnancy, Healthcare workers (high exposure risk), Lack of vaccination

What's the nurse tx of influenza virus

Monitor vital signs (fever, oxygen levels, respiratory status)., Encourage hydration (prevent dehydration from fever and sweating)., Promote rest (reduces energy expenditure)., Oxygen therapy (if experiencing difficulty breathing)., Droplet precautions (wear masks, isolate the patient if necessary)., Educate on hand hygiene (reduce transmission)., Encourage vaccination (flu shots annually).

What medication can be used with in 48 hours to reduce symptoms of the influenza virus?

Oseltamivir (Tamiflu), Zanamivir (Relenza), Baloxavir (Xofluza)

When an adult client with a diagnosis of pneumonia is admitted to the unit, the nurse observes symptoms of shaking chills and a fever of 104.2°F (40.1°C). A chest x-ray and sputum specimens for culture and sensitivity are ordered. To determine whether the pneumonia is caused by a bacteria or virus, the nurse asks the client about the onset of the symptoms. What is the rationale for the nurse's questioning?

The symptoms of bacterial pneumonia usually come on rapidly and tend to be more severe.

The nurse provides crushed ice chips to the client who mouth breathes. What is the best method for calculating the volume of ice the client swallows for the purpose of intake and output?

Melt a similar amount of ice and measure the volume.

The nurse applies a pulse oximeter to monitor the client's oxygenation. For what pulse oximetry measurement should the nurse provide the client with oxygen by nasal cannula?

88%

The client who has been diagnosed with pneumonia has difficulty expectorating respiratory secretions. What nursing action is most appropriate when planning to obtain the ordered sputum specimen?

Provide the client with a generous fluid intake.

What time of day is best for the nurse to obtain a sputum specimen from the client?

On awakening

What statement best suggests that the client understands the nurse's instruction on how to handle the sputum specimen container?

"I must not touch the inside of the container."

What assessment finding indicates that the client has most likely developed pleurisy as a result of the pneumonia?

Pain when breathing

The nurse advises the client about reducing the potential for acquiring future respiratory infections. What immunization should the nurse advise the client to receive yearly?

Fluzone

Penicillin by I.M. injection is ordered for the client diagnosed with pneumococcal pneumonia. When the client asks why the physician chose this particular drug to treat the pneumonia, what response by the nurse is best?

"The sensitivity report showed the organism is often killed by penicillin."

The nurse prepares to administer penicillin G to a client. The prescription reads: penicillin G potassium 300,000 units I.M. q.i.d. The directions on the label state, "This vial contains 1,000,000 units of penicillin G potassium. Add 9.6 mL sterile water for injection to reconstitute the powder for a concentration of 100,000 units/mL." How many milliliters of the reconstituted medication should the nurse administer to the client? Record your answer in the nearest whole number.

3mL

If a client is allergic to penicillin, the nurse should anticipate a hypersensitivity response to what other group of antibiotics?

Cephalosporins

Nurse volunteers speak to older adults during a community-wide immunization campaign. Other than obtaining a vaccination against influenza prior to flu season, what nursing advice is most helpful to high-risk clients who want to avoid getting influenza?

Avoid crowded places.

A client is seen in the physician's office and is given oseltamivir, an antiviral medication for the client's symptoms of fever, chills, muscle aches, rhinitis, and sore throat related to influenza. When the nurse is instructing the client on the effectiveness of oseltamivir, what instruction point is essential?

Oseltamivir must be started within 12 to 24 hours of the first symptoms

When caring for a client with influenza, what nursing assessment findings are signs and symptoms of hypoxia? Select all that apply.

Cyanosis, Tachypnea, Use of accessory muscles to breathe, Restlessness

A nurse working in an assisted living facility notes that an elderly client with influenza has a fever of 104.6°F (40.3°C) and a dry cough. The client reports sore muscles and a headache. The nurse instructs the unlicensed assistive personnel to encourage the client to consume extra fluids. If the client has normal cardiovascular and renal function, what is an appropriate goal for oral intake in the next 24-hour period?

3,000 mL

The physician orders the nurse to give two acetaminophen tablets orally every 4 hours, as needed, if the client has a temperature over 102°F (38.9°C) and to give a tepid sponge bath at the same time. What response is the best indication that the nurse should discontinue the client's sponge bath?

Chills

How long after administering the tuberculin skin test should the nurse inspect the client's injection site?

48 hours

The client asks the nurse, "What is the significance of a positive tuberculin skin test?" What explanation is most accurate?

You have antibodies against tuberculosis."

When a previously negative client has a positive reaction to a tuberculin skin test, what action is taken next?

Antituberculosis drugs will be prescribed.

The nurse cares for a client with a tentative admitting diagnosis of tuberculosis. What type of transmission precaution would the nurse follow during the client's care?

Airborne precautions

The client being cared for with transmission-based precautions feels shunned and abandoned. What nursing measure would be most helpful?

Interact with the client at frequent intervals

The physician prescribes a combination of rifampin and isoniazid to treat the client's tuberculosis. When the client asks the nurse about why the physician has prescribed two drugs, what response is most accurate?

Using two or more drugs lowers the potential for bacterial resistance.

What health measure is most important for the nurse to emphasize when instructing the client on how to prevent the transmission of tuberculosis while undergoing home drug therapy?

Cover your nose and mouth when coughing.

Aware that the client must manage nutritional needs on a very low income after being discharged, the nurse reinforces the dietitian's instructions. If the client identifies that lunches include the following foods, what meal is the most nutritious?

Meatless chili with beans, corn bread, and milk

The client diagnosed with tuberculosis is discharged but continues to have evidence of the tubercle bacilli in sputum after 6 weeks of drug therapy. What question is most important for the nurse to ask the client at this time?

Have you taken all your medications as prescribed?"

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying I have been drinking tons of water. How am I dehydrated? What response by the nurse is best?

Breathing so quickly can be dehydrating

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best?

"Older people often have vague symptoms, so an x-ray is essential."

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