A client receiving chemotherapy develops a cough that is productive of yellow-tinged sputum. After determining that the client is afebrile, which is the priority action for the practical nurse (PN) to take?
Plan to re-assess the client's temperature in two hours.
Notify the charge nurse of the assessment findings.
Measure and record the client's intake and output.
Provide oral hygiene on a regular, frequent schedule.
The Correct Answer is B
A. Re-assessing the client’s temperature is important but not the priority action since the client is currently afebrile and the cough with yellow sputum could indicate an infection or other condition needing immediate attention.
B. Notifying the charge nurse of the assessment findings is the priority because the yellow-tinged sputum in a client receiving chemotherapy might indicate an infection or complication that requires further investigation and possible intervention.
C. Measuring and recording intake and output is important for overall fluid balance but does not address the immediate concern of a productive cough with potential infection.
D. Providing regular oral hygiene is part of general care but does not address the potential underlying cause of the productive cough and yellow-tinged sputum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E","dropdown-group-3":"D"}
Explanation
- Dark Room Lighting
Consistent with Elder Mistreatment: A dark, uninviting environment can indicate neglect or lack of proper care. It may reflect poor living conditions or neglect of the client's environment, which can be a sign of mistreatment. - Malnutrition
Consistent with Elder Mistreatment: The client’s low weight (98 lb) relative to her height (5 ft 4 in) suggests potential malnutrition. Malnutrition can be a sign of neglect, as the client might not be receiving adequate food or nutrition, which is a form of mistreatment. - Pressure Injuries
Consistent with Elder Mistreatment: Although the pressure injuries have closed, the presence of Stage II pressure ulcers in the past indicates a lack of proper care and attention to the client’s needs. Pressure ulcers are a common sign of neglect in care settings.
Not Consistent with Elder Mistreatment
- Poor Hygiene
Not Consistent: The client appears clean and healthy with no issues in skin condition or oral hygiene, so this is not a sign of mistreatment. - Bilateral Leg Edema
Not Consistent: While edema might be a concern in heart failure management, it is not specifically indicative of elder mistreatment. - Short Term Memory Loss
Not Consistent: Short-term memory loss is not necessarily a sign of mistreatment; it could be related to aging or medical conditions.
Correct Answer is A, F, E
Explanation
A. Take the child's pulse
Assessing the pulse is crucial to determine if the child has a heartbeat and to evaluate the effectiveness of CPR. This helps to determine the current cardiovascular status of the child and the urgency of further resuscitation efforts.
F. Determine if the child's airway is clear
Ensuring a clear airway is a priority in any emergency situation. A blocked airway can prevent effective ventilation and oxygenation, which is critical for a child who has experienced a near-drowning incident.
D. Start a peripheral IV line
Starting a peripheral IV line is important for administering fluids and medications that may be necessary for resuscitation and stabilization. It allows for rapid access to the child's circulatory system for necessary interventions.
E. Look for any open wounds
Checking for open wounds is necessary to identify any immediate sources of bleeding or potential infections that need to be addressed. It is part of a thorough initial assessment to ensure comprehensive care for the child.
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