A nurse is admitting a client who has meningococcal meningitis. Which of the following actions should the nurse take first?

Administer antibiotic therapy to the client.

Provide the client with analgesics as needed.

Initiate droplet precautions for the client.

Educate the client about the meningococcal vaccine

Answer and Explanation

The Correct Answer is C

A. Administer antibiotic therapy to the client. This is a priority intervention, but it is not the first action. Before administration, infection control measures should be in place.

B. Provide the client with analgesics as needed. Pain management is important but is not the first priority. The spread of infection must be controlled immediately.

C. Initiate droplet precautions for the client. Meningococcal meningitis is highly contagious. Droplet precautions (mask, private room) must be initiated immediately to prevent transmission before other interventions.

D. Educate the client about the meningococcal vaccine. Vaccination is a preventive measure but does not address the immediate risk of infection spread.

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Correct Answer is C

Explanation

A. Pulse oximetry reading of 95%. COPD clients often have lower baseline oxygen levels (88-92%), making this reading unexpectedly high.

B. Decreased depth of respirations. COPD typically causes shallow and rapid breathing due to air trapping.

C. Flaring of the nostrils: Nostril flaring is a sign of increased respiratory effort, which is common in COPD exacerbations.

D. Respiratory rate of 16/min. → Normal range (12-20/min), not an expected finding during dyspnea.

A. Vocal quality B. Blood pressure C. Albumin D. BMI E. Dentition F. Bowel pattern G. Lung sounds H. Temperature I. Secretions J. Posture

Correct Answer is ["A","D","F","G","H","I","J"]

Explanation

A. Vocal quality – The client’s voice is hoarse and weak on Day 30, which may indicate dehydration, malnutrition, or an underlying respiratory issue.

B. Blood pressure – The client's blood pressure has slightly decreased but remains within a normal range, so it does not require immediate follow-up.

C. Albumin – Serum albumin levels are still within normal range.

D. BMI – The drop from 20 to 19 suggests unintentional weight loss, which could indicate malnutrition, inadequate intake, or an underlying illness.

E. Dentition –No difficulty in chewing reported.

F. Bowel pattern – The client has constipation for three days, which may require intervention to prevent complications like fecal impaction or discomfort.

G. Lung sounds – Diminished breath sounds at the bases may indicate fluid accumulation, atelectasis, or respiratory infection, requiring further evaluation.

H. Temperature – The client’s fever (38.1°C/100.6°F) suggests a possible infection and requires monitoring for underlying illness.

I. Secretions – Thick oral secretions may indicate dehydration, poor oral hygiene, or a swallowing issue, requiring follow-up to prevent aspiration.

J. Posture – The client’s slumped posture and fatigue could indicate weakness, nutritional deficiencies, or an underlying neurological or musculoskeletal problem.

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A nurse is admitting a client who has meningococcal meningitis. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a client in a long-term care facility. Exhibits Which of the following assessment findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","D","F","G","H","I","J"]

Explanation

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