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 practicing strength-building exercises for the arms, such as isometric exercises for the biceps and triceps, is beneficial for overall crutch use, it does not directly indicate proper crutch walking technique.
B. This choice is not correct for a three-point gait, especially in the case of a broken foot. In a three-point gait, the client should avoid bearing weight on the affected leg, as this gait is used to promote healing of a non-weight-bearing limb.
C. This behavior indicates a correct understanding of crutch walking. In the three-point gait, the client should bear weight on the crutches' handles and not on the armpits, which helps prevent nerve damage and provides better stability.
D. While it is important for safety to ensure that the rubber tips of the crutches are intact and not worn out, this behavior does not directly demonstrate the client’s understanding of the three-point gait technique.

A. Add the second portion of the feeding before the syringe is completely empty. B. Use 25 mL of water between the two portions of the feeding to flush the GT. C. Raise the syringe barrel higher to increase the flow rate of the bolus feeding. D. Flush the tube with 50 mL of water between the two portions of the feeding.

Correct Answer is D

Explanation

A. This instruction is not recommended because adding the second portion of the feeding before the syringe is empty can lead to inconsistent feeding rates and potential complications, such as overloading the stomach with too much formula at once.
B. Flushing the GT with water between portions of feeding is a good practice to prevent clogging and to ensure that all formula is delivered. However, 25 mL of water is generally not enough; standard practice typically involves using 30 to 60 mL of water for effective flushing. This option is close but not as specific as the recommended volume.
C. Raising the syringe barrel can increase the flow rate of the feeding, but this approach should be used with caution. Rapid flow can cause gastrointestinal discomfort or cramping. The primary focus should be on ensuring proper flushing and administration rather than manipulating the flow rate in this way.
D. This option is the best practice because flushing the GT with 50 mL of water between portions of the feeding helps to clear any remaining formula from the tube and prevents clogging. Proper flushing also helps ensure that the entire dose of formula is delivered and maintains tube patency.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is demonstrating three-point gait crutch walking to an older adult man who broke his foot while playing soccer with his grandchildren. Which behavior indicates that the client understands proper crutch walking?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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