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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While providing practical advice is useful, this response does not directly address the client's current emotional state or frustration. The immediate need is to support the client emotionally rather than instructing them on dressing techniques. It may also come off as dismissive of the client’s feelings.
B. This response is the most appropriate because it acknowledges and validates the client’s emotional experience. By recognizing their frustration, the nurse shows empathy and understanding, which can help in building a therapeutic relationship. It also opens up a dialogue for the client to express their feelings and concerns, which can improve their overall comfort and cooperation.
C. While education on dressing techniques is beneficial, this response does not address the client's immediate frustration or emotional needs. It also postpones support and could make the client feel like their current struggles are not being adequately addressed in the moment.
D. This response is defensive and does not address the client’s immediate emotional needs. It may escalate the situation by making the client feel like they are being reprimanded for their behavior. It is important to handle such situations with empathy and support rather than focusing on institutional policies.
Correct Answer is B
Explanation
A. While it is true that using proper techniques can reduce the risk of back injuries for healthcare providers, this is not the primary purpose of the log rolling technique. The main goal of log rolling is to protect the client’s spinal alignment rather than focusing on the safety of the staff.
B. This is the best explanation for the purpose of using the log rolling technique. Log rolling is designed to keep the client’s spine in a straight, aligned position while turning. This technique is particularly important for clients with spinal injuries or conditions where maintaining spinal alignment is crucial to prevent further injury or complications.
C. While it is true that turning a client is generally better for skin integrity than pulling, this explanation does not specifically address the purpose of log rolling. Log rolling is more focused on maintaining spinal alignment rather than solely on reducing skin damage.
D. Using two or three people can indeed increase safety during the turning process and help in managing the client more effectively, but this explanation does not capture the primary purpose of the log rolling technique itself.
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