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.

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

Explanation

A. This term refers to the passage of fresh blood through the anus, usually indicating lower GI bleeding (such as from the colon or rectum). It is a common and significant sign of GI bleeding.
B. Hypertension (high blood pressure) is generally not a sign of GI bleeding. In fact, GI bleeding typically leads to hypotension (low blood pressure) due to volume loss, making this choice incorrect.
C. Tarry stool (melena) indicates the presence of digested blood in the stool, typically resulting from upper GI bleeding. It appears black and sticky and is a common sign of GI bleeding.
D. This refers to vomiting that looks like coffee grounds, which indicates that blood has been present in the stomach and has undergone digestion. This is a classic sign of upper GI bleeding and is a significant symptom.
E. Hematemesis is the vomiting of blood, which can be bright red or resemble coffee grounds, depending on the source and severity of the bleeding. It is a common and serious sign of GI bleeding, particularly from the upper GI tract.

A. Phenazopyridine B. Phentolamine C. Vitamin B6 (Pyridoxine) D. Pyrazinamide

Correct Answer is C

Explanation

A. This medication is used primarily to relieve urinary tract discomfort and does not have any role in preventing peripheral neuropathy associated with INH. It is not relevant in this context.
B. Phentolamine is an alpha-adrenergic antagonist used to treat hypertension and manage pheochromocytoma. It has no association with preventing peripheral neuropathy related to INH and is not appropriate for this patient.
C. Isoniazid can cause peripheral neuropathy by interfering with the metabolism of pyridoxine (Vitamin B6). Administering pyridoxine can help prevent this side effect by replenishing the vitamin and supporting nerve health.
D. Pyrazinamide is another anti-tuberculosis medication that works alongside INH. While it is effective for tuberculosis, it does not prevent peripheral neuropathy and may even have its own side effects.

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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

Which of the following are common signs or symptoms of GI bleeding? (Select all that apply)

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

Explanation

An RN is caring for a patient with Tuberculosis who is to receive a new prescription for Isoniazid (INH). The nurse knows that INH can cause peripheral neuropathy. To help prevent this from happening, the nurse can ask the provider for:

Correct Answer is C

Explanation

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