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. Increasing intestinal peristalsis is not a primary goal related to managing a hiatal hernia. While peristalsis is important for digestion, the focus should be on the esophagus and stomach.
B. Preventing esophageal reflux is the main goal for clients with a hiatal hernia, especially sliding type, as the hernia can cause the stomach to push into the esophagus, leading to reflux symptoms. Strategies to prevent reflux may include dietary modifications and positioning.
C. Promoting effective swallowing may be important in some contexts, but it is not a primary goal associated with managing a hiatal hernia.
D. Maintaining intact oral mucosa is generally a broader nursing goal and not specific to the management of a hiatal hernia. The focus should be on preventing reflux rather than oral mucosa integrity in this case.

A. Over-enunciate word syllables. B. Exaggerate nonverbal expressions. C. Decrease speaking speed. D. Raise voice volume to a shout.

Correct Answer is C

Explanation

A. Over-enunciating word syllables can be perceived as patronizing and may not improve understanding for clients with hearing difficulties.
B. Exaggerating nonverbal expressions can help convey meaning, but it does not address the immediate need for clear verbal communication.
C. Decreasing speaking speed allows the client more time to process what is being said, which is particularly important for older adults who may need additional time to understand spoken words.
D. Raising voice volume to a shout may not be necessary and could distort the clarity of speech, making it harder for the client to understand.

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Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Correct Answer is B

Explanation

An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

Correct Answer is C

Explanation

Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?

Exhibits Which of the following does the nurse anticipate the healthcare provider to prescribe during morning rounds? Select 4 findings.

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

Exhibits Which prescriptions would the nurse question? Select all that apply.

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 emphysema is reporting difficulty in breathing and exhibiting audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?