A client is admitted with possible pneumonia. When entering the room, the nurse observes the client's face as seen in the picture. Which prescription should the nurse implement first?

Measure body temperature.

Administer PRN oxygen.

Send for chest x-ray.

Obtain sputum for culture.

Answer and Explanation

The Correct Answer is B

A.   Measuring body temperature is important in assessing the client’s overall condition and identifying a fever, which is common in pneumonia. However, while it provides useful information about the client's status, it is not the most urgent action compared to interventions that could immediately impact the client’s respiratory function or confirm the diagnosis.
B.   Administering PRN (as needed) oxygen is crucial if the client shows signs of hypoxia or difficulty breathing. If the client's face appears cyanotic or if they are experiencing respiratory distress, this action should be prioritized to ensure adequate oxygenation.
C.   A chest x-ray is essential for diagnosing pneumonia and assessing the extent of lung involvement. However, while it is critical for diagnosis, addressing immediate respiratory needs and symptoms takes precedence.
D.   Obtaining sputum for culture is important for identifying the causative organism and guiding antibiotic therapy. However, this action is less urgent than ensuring the client’s immediate respiratory needs are met and confirming the diagnosis through imaging.

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Correct Answer is C

Explanation

A. While voiding after intercourse can help reduce the risk of urinary tract infections (UTIs), it is not directly related to preventing vaginal tears. This practice is more relevant for preventing infections rather than addressing the issue of tissue trauma or dryness that may lead to tearing.
B. Regular well-woman exams are important for overall gynecological health and early detection of potential issues, but they do not directly address the immediate concern of preventing vaginal tears during intercourse.
C. Vaginal dryness is a common issue in older women, often due to decreased estrogen levels. Dryness can make vaginal tissues more susceptible to tearing during intercourse. Using vaginal lubricants can help reduce friction and prevent tears, making this the most relevant and practical advice for the client in this situation.
D. While certain positions may be more comfortable and could potentially reduce the risk of tearing, this advice is secondary to addressing the fundamental issue of vaginal dryness. Focusing on lubrication provides a more direct and effective approach to preventing tears.

A. Compare the client's manifestations with the defining criteria of related problems. B. List the nursing actions that need to be implemented most immediately. C. Review the priority nursing problems included in the plan of care. D. Ensure that all treatments prescribed by the healthcare provider have been initiated.

Correct Answer is C

Explanation

A. This action involves assessing how the client’s current symptoms and manifestations align with the criteria of the nursing problems identified. By doing this, the nurse can ensure that the goals set are directly related to addressing these specific issues.
B. While prioritizing nursing actions is important for immediate care needs, listing these actions is more related to the implementation phase rather than the goal-setting phase. Goals are broader and focus on what outcomes are desired for the client, while nursing actions are specific steps taken to achieve those goals.
C. Reviewing the priority nursing problems helps in identifying the most urgent issues that need to be addressed. This review is essential for setting appropriate goals, as it ensures that the goals reflect the most pressing needs of the client.
D. Ensuring that prescribed treatments have been initiated is part of the implementation phase of care. While it is important for the overall management of the client’s health, this step does not directly involve goal setting.

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A client is admitted with possible pneumonia. When entering the room, the nurse observes the client's face as seen in the picture. Which prescription should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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