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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Securing a disposable collar is not the most important action during the tie change.
B. Leaving the old tube in place until the new ones are secure is critical to maintain the airway and prevent accidental dislodgement of the tracheostomy tube, ensuring the client can breathe effectively during the procedure.
C. Placing knots laterally may help reduce irritation but does not address the immediate concern of securing the airway during the tie change.
D. Securing ties close to the tube can lead to pressure injuries and irritation but is not the priority compared to ensuring airway security.

A. Risk for aspiration related to difficulty swallowing. B. Chronic pain related to tissue destruction by tumor. C. Imbalanced nutrition less than body requirements. D. Anxiety and grieving related to progression of disease.

Correct Answer is A

Explanation

A. The priority nursing problem is the risk for aspiration related to difficulty swallowing (dysphagia). This condition poses an immediate risk to the client's safety as they may inhale food or liquids into the lungs, leading to aspiration pneumonia, which can be life-threatening.
B. While chronic pain is significant, addressing the risk of aspiration is more urgent in this context, especially considering the client's current symptoms.
C. Imbalanced nutrition is a concern, but it is secondary to the immediate risk posed by dysphagia and aspiration.
D. Although anxiety and grieving are important to address, they do not present an immediate threat to the client’s safety compared to the risk of aspiration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?

Correct Answer is B

Explanation

The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

Correct Answer is A

Explanation

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

Exhibits The client undergoes several days of antibiotic and respiratory treatment for his pneumonia. Mark whether the assessment findings indicate that the treatment was effective or ineffective. Each row must have one option selected.

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?

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

Exhibits Choose the most likely options for the information missing from the statement by selecting from the lists of options provided. Based on the information that the nurse has about the client, he likely has dropdownrelated todropdown