A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia.

Exhibits

Which of the following actions should the nurse take first?

Administer oxygen via nasal cannula.

Obtain a sputum culture.

Administer an antipyretic medication.

Encourage the client to increase fluid intake.

Answer and Explanation

The Correct Answer is A

Choice A Rationale: Administeíing oxygen via nasal cannula is the fiíst píioíity in this scenaíio. ľhe client’s oxygen satuíation is 88% on íoom aií, which indicates hypoxemia. Píoviding supplemental oxygen will help impíove the client’s oxygenation and alleviate symptoms of shoítness of bíeath. Ensuíing adequate oxygenation is cíucial to píevent fuítheí íespiíatoíy distíess and potential complications.
Choice B Rationale: Obtaining a sputum cultuíe is impoítant to identify the causative oíganism of the client’s íespiíatoíy infection and guide appíopíiate antibiotic theíapy. Howeveí, this action is not the immediate píioíity. Addíessing the client’s hypoxemia by administeíing oxygen takes píecedence to stabilize the client’s condition.
Choice C Rationale: Administeíing an antipyíetic medication can help íeduce the client’s feveí and impíove comfoít. Howeveí, this is not the immediate píioíity. ľhe client’s hypoxemia and íespiíatoíy distíess need to be addíessed fiíst by administeíing oxygen.
Choice D Rationale: Encouíaging the client to incíease fluid intake is impoítant foí maintaining hydíation and helping to thin íespiíatoíy secíetions. Howeveí, this action is not the immediate píioíity. ľhe client’s hypoxemia and íespiíatoíy distíess need to be addíessed fiíst by administeíing oxygen.

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Correct Answer is A

Explanation

Choice A rationale
Asking specifically about alcohol, marijuana, cocaine, heroin, and amounts provides a clear and direct approach to obtaining accurate information about the client’s substance use. This method helps in identifying potential health risks and planning appropriate care.
Choice B rationale
Using the term “illegal” or “illicit” to describe street drugs may cause the client to feel judged or defensive, which can hinder open communication. It is better to ask about specific substances directly.
Choice C rationale
Allowing the client to decline answering social questions may result in incomplete health history, which can affect the quality of care provided. It is important to encourage clients to share relevant information while ensuring confidentiality.
Choice D rationale
Obtaining a drug urine screen to verify the legitimacy of the client’s stated history is not an appropriate initial assessment technique. Trust and rapport should be established first through direct questioning.

A. Fissuring. B. Excoriation. C. Papules. D. Wheals.

Correct Answer is D

Explanation

Choice A rationale
Fissuring refers to deep cracks or splits in the skin. While it can occur in various skin conditions, it is not a typical manifestation of an allergic reaction to an insect bite.
Choice B rationale
Excoriation refers to a scratch or abrasion on the surface of the skin, often resulting from scratching due to itching. While this can occur secondary to an allergic reaction, it is not a primary characteristic of such reactions.
Choice C rationale
Papules are small, raised, solid bumps on the skin that are typically less than 1 centimeter in diameter. They can be a result of various skin conditions, but they are not specifically associated with allergic reactions to insect bites.
Choice D rationale
Wheals, also known as hives or urticaria, are raised, red or skin-colored welts on the skin that often itch and can appear rapidly in response to an allergen such as an insect bite. They are a characteristic feature of allergic reactions and are caused by the release of histamine.

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A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia. Exhibits Which of the following actions should the nurse take first?

Nursing Test Bank

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Correct Answer is D

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A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia.

Exhibits

Which of the following actions should the nurse take first?