A nurse is assessing a newly admitted client whose chief complaint is “coughing up blood” and whose recent history includes a productive cough and night sweats. What is the nurse’s priority intervention?

Initiate droplet precautions.

Consider standard precautions to be sufficient.

Transfer the client to a positive pressure room.

Initiate airborne precautions.

Transferring the client to a positive pressure room is inappropriate. Positive pressure rooms are designed to keep contaminants out and are used for protecting immunocompromised patients from infections. For a client with suspected TB, a negative pressure room is required to prevent the spread of infectious particles to other areas.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Initiating droplet precautions is not sufficient for a client presenting with symptoms such as coughing up blood, productive cough, and night sweats. These symptoms are indicative of possible tuberculosis (TB), which is an airborne disease. Droplet precautions are used for infections spread through large respiratory droplets, such as influenza or pertussis, but not for TB.

Choice B reason:

Considering standard precautions to be sufficient is incorrect. Standard precautions are the basic level of infection control that should be used in the care of all patients to prevent the spread of infections. However, for a client with symptoms suggestive of TB, additional airborne precautions are necessary to prevent the spread of the disease.

Choice C reason:

Choice D reason:

Initiating airborne precautions is the correct intervention. Airborne precautions are necessary for diseases that are transmitted through smaller respiratory droplets that can remain suspended in the air and be inhaled by others. Tuberculosis is one such disease, and initiating airborne precautions helps to prevent the spread of the infection to healthcare workers and other patients.

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Correct Answer is A

Explanation

Choice A reason:

Sitting upright is the best position for a respiratory assessment. This position allows for optimal lung expansion and makes it easier to auscultate breath sounds accurately. It also helps in observing the client’s breathing pattern and effort.

Choice B reason:

Semi-Fowler’s position, where the head of the bed is elevated to 30-45 degrees, is often used for clients with respiratory issues to promote lung expansion and reduce the risk of aspiration. However, it is not as effective as the sitting upright position for a thorough respiratory assessment.

Choice C reason:

The supine position, where the client lies flat on their back, is not ideal for a respiratory assessment. This position can limit lung expansion and make it more difficult to hear breath sounds clearly.

Choice D reason:

The side-lying position is also not suitable for a respiratory assessment. This position can cause uneven lung expansion and make it challenging to assess both lungs accurately.

A. Pulmonary function testing. B. Mechanical ventilation. C. Chest x-ray. D. 2 liters of oxygen via nasal cannula.

Correct Answer is B

Explanation

Choice A reason:

Pulmonary function testing is not the immediate priority for a client with status asthmaticus who is showing signs of respiratory failure, such as diminished breath sounds and confusion. Pulmonary function tests are useful for diagnosing and assessing the severity of asthma but are not appropriate during an acute, life-threatening exacerbation.

Choice B reason:

Mechanical ventilation is the correct intervention for a client with status asthmaticus who is exhibiting signs of respiratory failure. Diminished breath sounds and confusion indicate severe airway obstruction and hypoxia, necessitating immediate intervention to secure the airway and ensure adequate ventilation. Mechanical ventilation helps to maintain oxygenation and ventilation until the underlying cause can be treated.

Choice C reason:

A chest x-ray can be useful in diagnosing complications such as pneumothorax or pneumonia in a client with status asthmaticus, but it is not the immediate priority when the client is showing signs of respiratory failure. The primary focus should be on stabilizing the client’s respiratory status.

Choice D reason:

Administering 2 liters of oxygen via nasal cannula is not sufficient for a client with severe status asthmaticus and signs of respiratory failure. High-flow oxygen delivery methods or mechanical ventilation are required to adequately support the client’s respiratory needs.

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A nurse is assessing a newly admitted client whose chief complaint is “coughing up blood” and whose recent history includes a productive cough and night sweats. What is the nurse’s priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a physical assessment on the respiratory system. Although the client is currently confined to bed, they have the strength and ability to move and reposition themselves. The nurse instructs the client to assume which position for the assessment?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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