An adult client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?

Administer a prescribed antipyretic.

Offer a prescribed PRN analgesic.

Suction to clear secretions from airway.

Obtain arterial blood gases.

Answer and Explanation

The Correct Answer is C

C. The client's weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise. Suctioning to clear secretions from the airway can help improve air exchange and alleviate respiratory distress.

A. The client's primary issue appears to be respiratory distress rather than fever.

B. Offering pain relief is important for overall comfort but it is not be the most immediate intervention needed to address the client's respiratory distress.

D. Arterial blood gases may provide valuable information but they may not be the most immediate intervention needed to address the client's respiratory distress.

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Correct Answer is D

Explanation

D. Bismuth subsalicylate, a component of the regimen, has salicylate in its composition, which can lead to an increased risk of bleeding when taken with aspirin, a known blood thinner.

A. Loperamide is an antidiarrheal medication commonly used to treat diarrhea. It is not directly related to the treatment of Helicobacter pylori (H. pylori) infection.

B. Ipratropium is a bronchodilator medication used to treat conditions such as chronic obstructive pulmonary disease (COPD) and asthma. It is not directly related to the treatment of H. pylori infection.

C. Famotidine is a histamine-2 (H2) receptor antagonist commonly used to reduce stomach acid production. It is not directly related to the treatment of H. pylori infection.

A. Identify effective pain relief measures. B. Provide a numeric pain scale. C. Ask the client to describe the pain. D. Observe body language and movement.

Correct Answer is C

Explanation

C. Asking the client to describe their pain allows the nurse to gather subjective information directly from the client, which can provide valuable insight into the quality, intensity, location, and duration of the pain.

A. This option focuses on pain management rather than pain assessment. While identifying effective pain relief measures is important, it does not directly address the need to assess the quality of the client's pain.

B. While numeric pain scales can be useful for quantifying pain intensity, they do not capture the quality or characteristics of the pain.

D. Observing body language and movement can provide valuable information about the client's pain experience, such as grimacing, guarding, or difficulty moving. However, this approach primarily assesses pain behaviors rather than the quality of the pain itself.

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record for which medication?

Correct Answer is D

Explanation

To assess the quality of an adult client's pain, which approach should the nurse use?

Correct Answer is C

Explanation

Patient Data Exhibits According to the client's vital signs, he is experiencing dropdown and dropdown

Patient Data Exhibits Which physician orders would the nurse anticipate being prescribed after reporting findings? (Select all that apply).

The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 mL of DW to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many glt/minute? (Enler numeric value only. If rounding is required, round to the nearest whole number.)

A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

An older adult client is hospitalized with a fractured femur. During a routine nursing assessment, the client repeatedly asks the nurse to "speak up" so that the client can hear the questions. Which action is best for the nurse to take?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?