Question

A nurse is caring for a client who has asthma and is taking fluticasone. For which of the following adverse effects should the nurse monitor?

Answer 1

Correct Answers:

Oral candidiasis

Rationale :

🌟 Fluticasone is an inhaled corticosteroid used for long-term control of asthma by reducing airway inflammation.

🌟 Because it is a corticosteroid, it can suppress local immune response in the oropharynx, increasing the risk of oral candidiasis (thrush).

🌟 Thrush presents with white patches in the mouth, soreness, and possible difficulty swallowing.

🌟 Clients should be instructed to rinse their mouth after each use to reduce fungal growth.

🌟 Therefore, oral candidiasis is a common and important adverse effect to monitor.

❌ Hypoglycemia

Corticosteroids are more likely to cause hyperglycemia, not hypoglycemia. Low blood sugar is not expected with fluticasone use.

❌ Hypertension

Systemic corticosteroids may elevate blood pressure, but inhaled fluticasone has minimal systemic effects at standard doses. Hypertension is not a common adverse effect.

❌ Polyuria

Polyuria is typically associated with diabetes or fluid imbalance. It is not related to inhaled corticosteroid therapy.

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Answer 2

Correct Answers:

Sudden onset of high fever, chills, severe muscle aches, and fatigue

Rationale :

🌸 Influenza is a viral infection characterized by abrupt onset of high fever, chills, myalgia, and profound fatigue.

🌸 Unlike the common cold, influenza symptoms are systemic and severe.

🌸 The virus triggers a strong inflammatory response, resulting in muscle aches and weakness.

🌸 Respiratory symptoms may be present, but systemic manifestations are more prominent.

🌸 Therefore, sudden high fever with severe muscle aches is classic for influenza.

❌ Persistent productive cough with greenish sputum and chest discomfort

Green sputum suggests bacterial infection, such as pneumonia or bronchitis. Influenza is viral and often presents with dry cough initially.

❌ Wheezing and shortness of breath after physical activity

This presentation is more consistent with asthma or reactive airway disease. It is not typical of influenza.

❌ Intense pruritus, erythema, and localized swelling following an insect bite

These findings indicate an allergic reaction, not a viral respiratory infection.

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Answer 3

Correct Answers:

Offer mechanical soft diets and provide small, frequent meals with fluids given between meals.

Rationale :

🌿 Clients with COPD often experience dyspnea and fatigue during meals due to increased work of breathing.

🌿 Large meals can increase abdominal distention, which restricts diaphragmatic expansion and worsens shortness of breath.

🌿 Providing small, frequent meals reduces energy expenditure and helps prevent early fatigue.

🌿 A mechanical soft diet decreases chewing effort, conserving oxygen and energy.

🌿 Giving fluids between meals rather than during meals prevents gastric fullness and allows optimal nutritional intake.

❌ Provide fluids during meals to aid digestion and hydration simultaneously

Fluids taken with meals increase stomach distention and can worsen dyspnea. This may reduce overall intake.

❌ Advise the client to lie down immediately after eating to facilitate digestion and comfort

Lying flat increases pressure on the diaphragm and can impair lung expansion. Upright positioning is recommended.

❌ Encourage large, high-calorie meals to be eaten quickly to meet nutritional needs

Large meals increase fatigue and oxygen demand. Eating quickly may also increase aspiration risk.

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Answer 4

Correct Answers:

Extra tracheostomy tubes (current size and one size smaller).

Rationale :

🌟 Accidental decannulation is a life-threatening emergency because it can cause airway obstruction.

🌟 Having an extra tracheostomy tube of the same size allows immediate reinsertion.

🌟 A tube one size smaller is necessary in case swelling prevents insertion of the original size.

🌟 Rapid replacement is essential to maintain airway patency and oxygenation.

🌟 Therefore, ensuring availability of replacement tracheostomy tubes is a critical safety measure.

❌ Oxygen mask to support respiration

An oxygen mask does not maintain airway patency if the tracheostomy tube is dislodged. Airway access must be restored first.

❌ Blood pressure cuff to monitor vitals

Monitoring vital signs is important but does not address airway loss. Airway management takes priority.

❌ Humidifier to maintain airway moisture

Humidification prevents mucus plugging but does not manage accidental decannulation.

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Answer 5

Correct Answers:

Respiratory alkalosis

Rationale :

🔥 In the early phase of status asthmaticus, the child experiences severe bronchospasm that leads to increased work of breathing.

🔥 The child initially compensates by hyperventilating, which causes excessive elimination of carbon dioxide (CO₂).

🔥 This decrease in CO₂ results in respiratory alkalosis on arterial blood gas (ABG) analysis.

🔥 At this stage, oxygen levels may still be maintained, but CO₂ levels drop due to rapid breathing.

🔥 Therefore, the initial ABG finding in suspected status asthmaticus is respiratory alkalosis.

❌ Mixed acidosis

Mixed acidosis may occur later if respiratory failure develops. It is not the expected early finding.

❌ Metabolic alkalosis

Metabolic alkalosis is not associated with acute asthma exacerbations. It typically relates to vomiting or diuretic use.

❌ Respiratory acidosis

Respiratory acidosis occurs in late-stage status asthmaticus when fatigue leads to hypoventilation and CO₂ retention. It signals impending respiratory failure.

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Answer 6

Correct Answers:

Decrease in respiratory rate and stabilization of vital signs

Rationale :

🌟 Successful treatment of influenza is reflected by improvement in systemic and respiratory stability, not just symptom relief.

🌟 Influenza often causes tachypnea, fever, and elevated heart rate due to systemic inflammation.

🌟 A decrease in respiratory rate and stabilization of vital signs indicate recovery and improved physiologic balance.

🌟 Normalizing vitals reflects resolution of infection-related stress on the body.

🌟 Therefore, stabilization of respiratory rate and vital signs is the most objective indicator of effective treatment.

❌ The patient expressing relief from body aches

Relief of aches is subjective and does not fully indicate physiologic recovery. Objective measures are more reliable indicators.

❌ Increased appetite and energy levels

Improved appetite is positive but may occur later in recovery. It is not the most immediate indicator of treatment success.

❌ Reduction in fever alone

Fever reduction is important but does not confirm full stabilization. Other vital signs must also normalize.

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Answer 7

Correct Answers:

Encourage frequent hand washing and avoiding crowded places during RSV season.

Rationale :

🌸 Respiratory syncytial virus (RSV) spreads primarily through direct contact and respiratory droplets.

🌸 Premature infants are at high risk due to immature immune systems and underdeveloped lungs.

🌸 Frequent hand hygiene significantly reduces viral transmission.

🌸 Avoiding crowded environments limits exposure to infected individuals.

🌸 Therefore, infection prevention through hand washing and exposure reduction is the most important preventive strategy.

❌ Administer palivizumab at least once every two months during RSV season

Palivizumab is given monthly, not every two months. Incorrect dosing reduces effectiveness.

❌ Advise the parents to allow only family members to visit

Family members can still transmit RSV. Restricting to family alone does not eliminate exposure risk.

❌ Ensure that the infant receives ribavirin immediately if they show symptoms

Ribavirin is not routinely used and is reserved for severe cases. Prevention is more effective than treatment.

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Answer 8

Correct Answers:

Administer enzymes with all snacks and meals

Rationale :

🌼 Children with cystic fibrosis (CF) have pancreatic insufficiency, leading to impaired digestion of fats, proteins, and carbohydrates.

🌼 Pancreatic enzyme replacement therapy (PERT) must be taken with every meal and snack to aid digestion.

🌼 Enzymes must mix with food in the stomach to function effectively.

🌼 Without consistent enzyme use, the child may develop malabsorption, steatorrhea, and poor weight gain.

🌼 Therefore, enzymes should be administered with all meals and snacks.

❌ Mix enzymes with hot foods

Heat can destroy enzyme activity. Enzymes should not be mixed with hot food.

❌ Provide enzymes 2 hours after meals

Enzymes must be taken at the start of meals to work properly. Delayed administration reduces effectiveness.

❌ Only administer enzymes with high-fat meals

Enzymes are needed for all meals and snacks, not just high-fat foods. Inconsistent use leads to malabsorption.

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Answer 9

Correct Answers:

Optic neuritis

Rationale :

🔷 Ethambutol (EMB) is an antitubercular medication commonly associated with optic neuritis, a serious dose-related adverse effect.

🔷 Optic neuritis manifests as blurred vision, decreased visual acuity, and red-green color discrimination difficulty.

🔷 This complication occurs due to inflammation of the optic nerve, which can lead to permanent vision loss if not detected early.

🔷 Clients taking ethambutol require baseline and periodic visual acuity testing during therapy.

🔷 Therefore, monitoring for visual changes is essential to prevent irreversible damage.

❌ Myocardial infarction

Ethambutol is not associated with acute cardiac ischemia. Myocardial infarction is unrelated to this medication.

❌ Thrombocytopenia

Thrombocytopenia is not a common adverse effect of ethambutol. It is more commonly associated with other medications such as heparin.

❌ Tendon rupture

Tendon rupture is linked to fluoroquinolone antibiotics, not ethambutol. It is not a known complication of TB therapy with EMB.

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Answer 10

Correct Answers:

Use sterile suctioning supplies.

Rationale :

✨ Tracheostomy suctioning involves direct access to the lower airway, which is normally sterile and highly susceptible to infection.

✨ Using sterile suctioning equipment and technique prevents introduction of microorganisms into the trachea and lungs.

✨ Failure to maintain sterility increases the risk of ventilator-associated pneumonia or tracheal infection.

✨ Sterile gloves, catheter, and saline (if used) are essential components of proper suctioning procedure.

✨ Therefore, maintaining strict sterile technique is the primary precaution to minimize infection risk.

❌ Administer prophylactic antibiotics

Antibiotics are not routinely given to prevent infection during suctioning. Unnecessary use increases risk of antibiotic resistance.

❌ Ensure the stoma site is coated with petroleum jelly

Petroleum jelly can trap moisture and promote bacterial growth. It is not part of sterile suctioning practice.

❌ Apply antiseptic to the outer cannula before suctioning

Cleaning the outer cannula does not prevent pathogens from entering the lower airway. Sterile internal suctioning technique is the key infection control measure.

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QLexNursing

1 :
A nurse is caring for a client who has asthma and is taking fluticasone. For which of the following adverse effects should the nurse monitor?

2 :
A nurse is assisting in the care of a client who has manifestations of an upper respiratory tract infection. Which of the following clinical findings should the nurse identify as consistent with influenza?

3 :
A nurse is caring for a client with COPD who is experiencing fatigue during meals. Which nursing intervention is most appropriate to optimize the client's nutritional intake while minimizing energy expenditure?

4 :
While preparing for tracheostomy suctioning, what specific equipment should you ensure is available to address accidental decannulation?

5 :
For a child with suspected status asthmaticus, what would the initial ABG likely show?

6 :
During the evaluation of a nursing intervention plan for an influenza patient, which outcome measurement would indicate successful treatment?

7 :
A nurse is educating the parents of a premature infant on RSV risk prevention. What is the most important strategy the nurse should emphasize for reducing the risk of RSV infection?

8 :
A child with cystic fibrosis is prescribed pancreatic enzyme replacement therapy. Which dietary advice should the nurse provide to the parents to enhance enzyme efficacy?

9 :
A nurse is assisting with the care of a client who has a new prescription for ethambutol (EMB) to treat tuberculosis. For which of the following potential adverse effects should the nurse plan to monitor the client?

10 :
What primary precaution should be taken when performing tracheostomy suctioning to minimize the risk of infection?

QLexNursing

1 : A nurse is caring for a client who has asthma and is taking fluticasone. For which of the following adverse effects should the nurse monitor?

2 : A nurse is assisting in the care of a client who has manifestations of an upper respiratory tract infection. Which of the following clinical findings should the nurse identify as consistent with influenza?

3 : A nurse is caring for a client with COPD who is experiencing fatigue during meals. Which nursing intervention is most appropriate to optimize the client's nutritional intake while minimizing energy expenditure?

4 : While preparing for tracheostomy suctioning, what specific equipment should you ensure is available to address accidental decannulation?

5 : For a child with suspected status asthmaticus, what would the initial ABG likely show?

6 : During the evaluation of a nursing intervention plan for an influenza patient, which outcome measurement would indicate successful treatment?

7 : A nurse is educating the parents of a premature infant on RSV risk prevention. What is the most important strategy the nurse should emphasize for reducing the risk of RSV infection?

8 : A child with cystic fibrosis is prescribed pancreatic enzyme replacement therapy. Which dietary advice should the nurse provide to the parents to enhance enzyme efficacy?

9 : A nurse is assisting with the care of a client who has a new prescription for ethambutol (EMB) to treat tuberculosis. For which of the following potential adverse effects should the nurse plan to monitor the client?

10 : What primary precaution should be taken when performing tracheostomy suctioning to minimize the risk of infection?

1 :
A nurse is caring for a client who has asthma and is taking fluticasone. For which of the following adverse effects should the nurse monitor?

2 :
A nurse is assisting in the care of a client who has manifestations of an upper respiratory tract infection. Which of the following clinical findings should the nurse identify as consistent with influenza?

3 :
A nurse is caring for a client with COPD who is experiencing fatigue during meals. Which nursing intervention is most appropriate to optimize the client's nutritional intake while minimizing energy expenditure?

4 :
While preparing for tracheostomy suctioning, what specific equipment should you ensure is available to address accidental decannulation?

5 :
For a child with suspected status asthmaticus, what would the initial ABG likely show?

6 :
During the evaluation of a nursing intervention plan for an influenza patient, which outcome measurement would indicate successful treatment?

7 :
A nurse is educating the parents of a premature infant on RSV risk prevention. What is the most important strategy the nurse should emphasize for reducing the risk of RSV infection?

8 :
A child with cystic fibrosis is prescribed pancreatic enzyme replacement therapy. Which dietary advice should the nurse provide to the parents to enhance enzyme efficacy?

9 :
A nurse is assisting with the care of a client who has a new prescription for ethambutol (EMB) to treat tuberculosis. For which of the following potential adverse effects should the nurse plan to monitor the client?

10 :
What primary precaution should be taken when performing tracheostomy suctioning to minimize the risk of infection?