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 C

Explanation

Choice A reason: Placing the client on cardiac monitoring is important, especially if there are signs of cardiac involvement or if the client is at risk for arrhythmias. However, it is not the primary intervention for hypernatremia. Hypernatremia primarily affects fluid balance and neurological status.

Choice B reason: Monitoring breath sounds every 4 hours is a good practice, particularly if there is a risk of fluid overload or respiratory complications. However, it does not directly address the issue of hypernatremia. The primary concern with hypernatremia is managing fluid balance and preventing further increases in serum sodium levels.

Choice C reason: Restricting fluids to 500 mL per day is a critical intervention for managing hypernatremia. Hypernatremia often results from a deficit in free water, leading to an elevated serum sodium level. Fluid restriction helps to prevent further increases in sodium concentration and assists in gradually correcting the imbalance. This intervention directly addresses the underlying issue of hypernatremia and helps to stabilize the client’s condition.

Choice D reason: Implementing safety precautions is important, especially if the client is experiencing neurological symptoms such as confusion or agitation. While safety precautions are necessary, they are not the primary intervention for correcting hypernatremia. The focus should be on managing fluid balance and serum sodium levels.

A. Improve the ciliary movement in the lungs. B. Increase your ability to take deep breaths. C. Loosen secretions in congested areas of the lungs. D. Increase the oxygen supply to your tissues.

Correct Answer is C

Explanation

Choice A reason:

Improving the ciliary movement in the lungs is not the primary purpose of chest physiotherapy. While ciliary movement is important for clearing mucus, CPT specifically aims to mobilize and remove secretions through techniques such as percussion, vibration, and postural drainage.

Choice B reason:

Increasing the ability to take deep breaths is not the main goal of chest physiotherapy. Although CPT can indirectly help improve lung function by clearing secretions, its primary purpose is to facilitate the removal of mucus from the lungs.

Choice C reason:

Loosening secretions in congested areas of the lungs is the most accurate reason for ordering chest physiotherapy. CPT helps to mobilize and clear mucus, which can improve ventilation and gas exchange, reduce the risk of infection, and aid in the recovery process.

Choice D reason:

Increasing the oxygen supply to your tissues is not the direct aim of chest physiotherapy. While clearing secretions can improve overall lung function and oxygenation, the primary goal of CPT is to remove mucus from the airways.

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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 priority nursing intervention for a client who has a serum sodium level of 154 mEq/L would be:

Correct Answer is C

Explanation

The client diagnosed with pneumonia asks the nurse, “Why did my physician order chest physiotherapy (CPT) for me?” Which response by the nurse is most accurate? Chest physiotherapy will:

Correct Answer is C

Explanation

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