How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a client in the intensive care unit.

Exhibits

Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Most Likely Condition:

The client is most likely experiencing Hospital-acquired pneumonia ©. This is indicated by the recent admission for pneumonia, persistent cough with greenish sputum, increased WBC count, and bilateral infiltrates on the chest X-ray.

Actions to Take:
  1. Administer IV antibiotics as prescribed (already in the provider’s prescriptions).
  2. Perform chest physiotherapy © to help clear the lungs.
 
   

Parameters to Monitor: 

  1. Oxygen saturation (A) to ensure the client is maintaining adequate oxygen levels.
  2. White blood cell count (D) to monitor the infection and response to antibiotics.
 
   

 

 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["A","C","D","E","F"]

Explanation

Choice A rationale
Double-checking all dosage calculations is a crucial error prevention technique. It helps ensure that the correct dose is administered and reduces the risk of medication errors. This step is especially important for medications like insulin, where precise dosing is critical.
Choice B rationale
This option seems incomplete and does not provide a clear error prevention technique. Therefore, it is not considered a correct choice.
Choice C rationale
Comparing the medication label to the order is essential to verify that the correct medication is being administered. This step helps prevent errors related to administering the wrong medication.
Choice D rationale
Using at least two client identifiers before administering a dose is a standard safety practice. It ensures that the medication is given to the correct patient and helps prevent errors related to patient misidentification.
Choice E rationale
Involving and educating clients in medication administration can help prevent errors by ensuring that clients are aware of their medications and can alert healthcare providers to any discrepancies. This collaborative approach enhances patient safety.
Choice F rationale
Documenting all medication in the electronic record as soon as it is given is crucial for maintaining accurate and up-to-date records. This practice helps prevent duplicate dosing and ensures that all healthcare providers have access to the most current information.

Correct Answer is C

Explanation

Choice A rationale
Removing dentures or other oral appliances is not the most critical intervention for a client with severe obstructive sleep apnea (OSA) who has received an opioid analgesic. The priority is to ensure airway patency.
Choice B rationale
Elevating the head of the bed to a 45-degree angle can help improve airway patency but is not as effective as applying the positive airway pressure device.
Choice C rationale
Applying the client’s positive airway pressure device (CPAP or BiPAP) is the most important intervention because it directly maintains airway patency and prevents respiratory compromise, which is crucial for a client with severe OSA2.
Choice D rationale
Putting and locking the side rails in place is important for safety but does not address the critical need to maintain airway patency in a client with severe OSA.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register