A nurse is caring for a client who has pneumonia. Assessment findings include T 100.4 deg F, RR 30, BP 130/76, HR 100, and SpO2 91% on room air. Which of the following is the PRIORITY intervention?

Perform a sputum culture

Instruct the patient to obtain yearly influenza vaccination

Administer oxygen therapy

Administer antibiotics

Answer and Explanation

The Correct Answer is C

A.   While obtaining a sputum culture is important for identifying the causative organism and guiding antibiotic therapy, it is not an immediate priority. Delaying this test briefly for critical interventions (like oxygen administration) is acceptable, as stabilizing the patient's oxygen levels is more urgent.
B.   Educating the patient about vaccination is important for long-term health and prevention of future respiratory infections. However, it does not address the current situation and does not provide immediate benefit for the acute episode of pneumonia.
C.   The patient has a SpO2 of 91%, which indicates hypoxemia (low oxygen levels in the blood). In pneumonia, adequate oxygenation is crucial to prevent further respiratory distress and potential complications. Administering oxygen therapy will help improve the oxygen saturation and support the patient’s respiratory function, making this the highest priority intervention.
D.   While antibiotics are essential for treating bacterial pneumonia, they may take time to exert their effects. In this acute scenario, the immediate need is to ensure the patient is adequately oxygenated. After oxygen is administered, antibiotics can be given promptly.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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

Explanation

A. Paper tape is gentler on fragile skin compared to standard adhesive tape. It reduces the risk of skin tears and bleeding, making it a safer option for patients with thrombocytopenia.
B. This option is not advisable. Mouthwash containing alcohol can irritate and dry out the mucous membranes in the mouth, potentially leading to ulcers or bleeding. Instead, an alcohol-free mouthwash should be used for oral care.
C. Aspirin is an antiplatelet agent that can increase the risk of bleeding. Patients on bleeding precautions should avoid aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) to minimize the risk of excessive bleeding.
D. A soft-bristle toothbrush or oral sponge is recommended for oral care to minimize trauma to the gums and mucous membranes. This helps reduce the risk of bleeding in patients with low platelet counts.
E. Using an electric shaver is safer than a traditional razor, as it reduces the risk of cuts and nicks that can lead to bleeding. This precaution is particularly important for patients with thrombocytopenia.

A. High serum Iron and Low MCV B. High serum Iron and Mean Corpuscular Volume (MCV) C. High Total Iron Binding Capacity: Low serum Iron and MCV D. None of the above

Correct Answer is C

Explanation

A. In iron deficiency anemia, serum iron levels are typically low due to a deficiency in iron. Additionally, the Mean Corpuscular Volume (MCV) is often low because the red blood cells produced are smaller than normal (microcytic).
B. Similar to option A, serum iron levels in iron deficiency anemia would be low, not high. The MCV may be low or normal, but it would not be high due to the production of microcytic red blood cells.
C. In iron deficiency anemia, TIBC is usually high because the body is trying to maximize iron transport in response to low iron levels. Serum iron is low, and the MCV is low due to the production of smaller red blood cells.
D. This option is incorrect because option C accurately describes the expected lab results in iron deficiency anemia.

View Question and Answer

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

A nurse is caring for a client who has pneumonia. Assessment findings include T 100.4 deg F, RR 30, BP 130/76, HR 100, and SpO2 91% on room air. Which of the following is the PRIORITY intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patients receiving chemotherapy are at risk for thrombocytopenia related to chemotherapy or disease processes. Which actions. are needed for patients who must be placed on bleeding precautions? (Select all that apply)

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

Explanation

Your patient has Iron deficiency anemia because of their pica. Which of the following lab results is EXPECTED in this condition?

Correct Answer is C

Explanation

A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching?

A patient with iron deficiency anemia who is taking oral iron supplements is evaluated by the nurse in the outpatient clinic. Which finding by the nurse is of MOST concern?

Your client is diagnosed with Pernicious Anemia. What is the MOST likely treatment that they will receive?

The nurse is reviewing lab results for a patient and the white blood cell (WBC) count is elevated at 12,000. Which of the following is a cause of increasing WBC count? (Select all that apply)

Which of the following is are appropriate nursing interventions to ensure the safety of a patient who is receiving Total Parenteral Nutrition (TPN)? (Select all that apply)

You are caring for a patient who has Sickle Cell Disease (SCD) who is in the hospital for an acute worsening of their disease. Your patient is receiving ATC opioids for their severe pain, when they suddenly report a new sharp pain in their left shoulder. What is your BEST action?

The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply.)