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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Free Nursing Study Resources

Correct Answer is ["C","E","H"]

Explanation

A. Send blood for a complete blood count, electrolytes: This is appropriate for assessing the client's overall health status and electrolyte balance, which may be affected by pneumonia and enalapril therapy.

B.Enalapril 10 mg every morning: This is the client's maintenance dose of enalapril for managing hypertension, and it should be continued unless there are specific contraindications or concerns about renal function.

C.Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase blood pressure and interfere with the antihypertensive effects of enalapril. Additionally, NSAIDs can potentially worsen renal function, which may already be compromised in a client with pneumonia.
D.Admit to the medical floor: This is appropriate for a client with pneumonia who may require close monitoring and management of respiratory status and other complications.
E.Supplemental oxygen 10 L/min via nasal cannula: High-flow oxygen can decrease respiratory drive and potentially worsen ventilation-perfusion (V/Q) matching, especially in clients with pneumonia.

F.Vital signs every 4 hours: Regular monitoring of vital signs is essential for assessing the client's response to treatment and identifying any signs of deterioration.

G.Continuous pulse oximetry: Continuous pulse oximetry provides real-time monitoring of oxygen saturation and helps assess the effectiveness of oxygen therapy and the client's respiratory status.

H.While a chest x-ray is often indicated for diagnosing pneumonia, ordering it "now" may not be necessary unless the client's condition is unstable or if there are specific concerns regarding the severity of the pneumonia

A. Encourage deep breathing and coughing exercises. B. Obtain vital signs every 2 hours during hospitalization. C. Provide an eye shield to be worn while sleeping. D. Teach a family member to administer eye drops.

Correct Answer is C

Explanation

C. After eye surgery, especially when there's been trauma like glass removal, it's crucial to protect the eye from further injury, particularly during sleep when movements may be involuntary and less controlled. An eye shield helps prevent inadvertent rubbing or trauma to the eye, promoting healing and reducing the risk of complications.

A. While deep breathing and coughing exercises are important for preventing respiratory complications after surgery, they are not the immediate intervention required following surgical removal of glass from the eye.

B. Monitoring vital signs is essential for assessing the client's overall health status and detecting any signs of complications. However, it is not a priority

D. While administering eye drops may be a part of postoperative care, it's not the immediate intervention required right after the surgical removal of glass from the eye.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits What order(s) would the nurse question? (Select all that apply.)

Correct Answer is ["C","E","H"]

Explanation

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

Correct Answer is C

Explanation

Patient Data Exhibits Mark whether the assessment findings indicate that the treatment was effective or ineffective. Assessment Findings

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB?

Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

Patient Data Exhibits What should the nurse do before applying the face mask? Select that apply.

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?