A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?

Obtain arterial blood gases.

Administer a prescribed antipyretic.

Offer a prescribed PRN analgesic.

Suction to clear secretions from airway.

Answer and Explanation

The Correct Answer is D

A. Obtaining arterial blood gases is important for assessing respiratory status but is not the immediate priority.
B. Administering an antipyretic can help reduce fever but does not address the immediate respiratory distress the client is experiencing.
C. Offering an analgesic can improve comfort but is not the priority intervention in this scenario.
D. Suctioning to clear secretions from the airway is the most critical intervention to improve the client’s respiratory status, especially given the weak cough effort and use of accessory muscles, indicating possible airway obstruction or ineffective clearance of secretions.

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Correct Answer is B

Explanation

A. Step-by-step verbal directions may be confusing for clients with Huntington's disease due to cognitive and motor difficulties.
B. Escorting the client to the cafeteria ensures safety and provides direct assistance, which is crucial given the potential for impaired judgment and coordination in Huntington's disease.
C. While using a map might help some clients, it may overwhelm or confuse others, particularly those with cognitive impairments associated with Huntington's disease.
D. Orienting the client to a color-coding system could also be confusing andmay not be an effective method of navigation for someone with cognitive challenges.

A. A positive sputum smear and culture. B. Vertigo and tinnitus. C. Decreased cough and sputum. D. Decreased appetite and weight loss.

Correct Answer is C

Explanation

A. A positive sputum smear and culture would indicate that the tuberculosis infection is still active, which is not an expected outcome of effective treatment with isoniazid.
B. Vertigo and tinnitus are not expected outcomes of isoniazid therapy; they may indicate side effects or adverse reactions, not effectiveness.
C. Decreased cough and sputum would demonstrate the effectiveness of isoniazid in treating active tuberculosis, as the medication should lead to symptomatic improvement and reduced bacterial load.
D. Decreased appetite and weight loss can be associated with tuberculosis but are not direct indicators of medication effectiveness.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

Correct Answer is B

Explanation

The antitubercular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness of this medication, which outcome can the nurse expect this client to exhibit?

Correct Answer is C

Explanation

A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?

Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?