A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?

Dry, occasional cough.

Temperature or Febrile 103 degrees F (39.4 degrees C)

Clear, watery drainage from the nose

Scratchy throat

Answer and Explanation

The Correct Answer is B

A.   Dry, occasional cough: A dry, occasional cough is a common symptom of upper respiratory infections and may not necessarily indicate a complication.
B.   Temperature or Febrile 103 degrees F (39.4 degrees C): A high fever (over 100.4 degrees F or 38 degrees C) is a concerning symptom that may indicate the development of a complication such as pneumonia or a secondary bacterial infection.
C.   Clear, watery drainage from the nose: Clear, watery drainage from the nose is typically associated with viral upper respiratory infections and may not necessarily indicate a complication.
D.   Scratchy throat: A scratchy throat is a common symptom of upper respiratory infections and may not necessarily indicate a complication.

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Correct Answer is A

Explanation

A. Obtain a sputum culture: Obtaining a sputum culture helps identify the causative organism of pneumonia, which guides appropriate antibiotic therapy.
B. Cough and deep breathe every 6 hours: While coughing and deep breathing exercises are important for preventing complications such as atelectasis, they are not specific to pneumonia treatment and may not be appropriate for all patients with pneumonia.
C. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is generally recommended for overall health but is not a specific intervention for pneumonia treatment.
D. Position the client prone: Positioning the client prone is not a standard intervention for pneumonia treatment. Depending on the severity and type of pneumonia, the client's positioning may vary, but prone positioning is not routinely recommended.

A. Potassium B. BUN C. WBC count D. RBC count

Correct Answer is C

Explanation

A. Potassium: Potassium levels are not typically used to diagnose infection. Elevated potassium levels may indicate other health conditions such as kidney dysfunction.
B. BUN (Blood Urea Nitrogen): BUN levels assess kidney function and are not directly related to the presence of infection.
C. WBC count (White Blood Cell count): An elevation in the WBC count, specifically the neutrophil count (neutrophilia), is indicative of the body's response to infection or inflammation.
D. RBC count (Red Blood Cell count): RBC count is not typically used to diagnose infection.
Elevated RBC count may indicate conditions such as dehydration or polycythemia.

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A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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