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 B

Explanation

Choice A rationale
Positive Homan’s sign bilaterally indicates deep vein thrombosis (DVT) but does not directly correlate with swelling.
Choice B rationale
2+ pitting edema of ankles bilaterally is a direct indication of swelling and supports the client’s statement about their feet swelling all the time.
Choice C rationale
Pedal pulses weak and thready indicate poor arterial circulation but do not directly confirm swelling.
Choice D rationale
Capillary refill in both feet greater than 3 seconds indicates poor peripheral perfusion but does not directly correlate with swelling.

A. White blood cell count (WBC). B. Blood urea nitrogen (BUN). C. Hematocrit. D. Glucose.

Correct Answer is C

Explanation

Choice A rationale
White blood cell count (WBC) is typically monitored to assess for signs of infection or inflammation. While it’s important to monitor WBC count in certain situations, such as suspected infection, melena itself is not directly indicative of an increased risk of infection.
Choice B rationale
Blood urea nitrogen (BUN) levels can be elevated in cases of gastrointestinal bleeding due to the breakdown of blood proteins in the gut. However, BUN is not the primary test to monitor in response to melena.
Choice C rationale
Hematocrit is the correct answer. Hematocrit levels are crucial to monitor in cases of melena because they provide information about the client’s red blood cell volume and can indicate the extent of blood loss.
Choice D rationale
Glucose levels are not directly related to melena. Monitoring glucose levels is essential for managing diabetes and other metabolic conditions but is not relevant to assessing the impact of gastrointestinal bleeding.

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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

Naxlex Comprehensive Predictor Exams

Which assessment finding supports the client statement, “My feet swell all the time?”

Correct Answer is B

Explanation

The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is C

Explanation

While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

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While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

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?

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

While interviewing a newly admitted older female client, the nurse observes that the client ignores Questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

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?