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. Lactulose typically increases the frequency of liquid stools as it helps to draw water into the intestines to facilitate bowel movements.
B. The primary therapeutic goal of lactulose in hepatic encephalopathy is to reduce ammonia levels in the blood, which should result in improved mental status and cognitive function.
C. While lactulose can affect fluid balance, an increase in urine output is not a direct therapeutic response associated with its use.
D. Although improvement in ambulation may occur as the client's mental status improves, it is not the primary expected outcome of lactulose treatment.

A. Hemoccult test on sputum collected from hemoptysis. B. Positive purified protein derivative (PPD) skin test. C. Sputum culture positive for Mycobacterium tuberculosis. D. Chest x-ray or computed tomography (CT).

Correct Answer is C

Explanation

A. A hemoccult test on sputum is used to detect blood and is not specific to TB.
B. A positive PPD skin test indicates exposure to TB but does not confirm active disease; further testing is required.
C. A sputum culture positive for Mycobacterium tuberculosis is the definitive test for confirming active tuberculosis, as it isolates the organism.
D. A chest x-ray or CT can suggest the presence of TB but does not provide a definitive diagnosis; culture is necessary for confirmation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

Correct Answer is B

Explanation

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Correct Answer is C

Explanation

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

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 multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?