An older adult client presents with dyspnea on exertion, cough with green sputum, fever, and fatigue. The nurse notes thick rhonchi/coarse crackles upon lung auscultation and the patient's chest X-ray shows bilateral consolidation. The nurse anticipates which of the following interventions?

Western Blot test

Initiation of broad-spectrum antibiotics

Initiation of Isoniazid and Rifampin

Antiretroviral therapy.

Answer and Explanation

The Correct Answer is B

A) "Western Blot test":
. The Western Blot test is typically used to confirm HIV infection after a positive enzyme-linked immunosorbent assay (ELISA). This test is not relevant for diagnosing pneumonia, which is the most likely cause of this patient's symptoms. The patient's presentation — including dyspnea on exertion, cough with green sputum, fever, fatigue, and bilateral consolidation on the chest X-ray — points to a respiratory infection (likely pneumonia) rather than an HIV-related issue.

B) "Initiation of broad-spectrum antibiotics":
. The patient's symptoms, including dyspnea, cough with green sputum, fever, fatigue, and bilateral consolidation on chest X-ray, strongly suggest community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP). In either case, broad-spectrum antibiotics are indicated to cover a wide range of potential bacterial pathogens, especially in older adults or those with comorbidities who may be at risk for more severe infections. Immediate treatment with antibiotics is necessary to prevent complications such as respiratory failure or sepsis. Once cultures and sensitivities are obtained, the antibiotics may be adjusted based on the specific pathogen.

C) "Initiation of Isoniazid and Rifampin":
. Isoniazid and Rifampin are used to treat tuberculosis (TB), but this patient’s symptoms do not indicate TB. The patient is experiencing acute respiratory symptoms, including fever, cough with sputum production, and consolidation on chest X-ray, which are more indicative of pneumonia than of tuberculosis. Although TB could present similarly, additional testing such as a TB skin test (TST) or sputum culture for acid-fast bacilli (AFB) would be necessary before initiating antitubercular therapy. The priority intervention here is antibiotic treatment for bacterial pneumonia.

D) "Antiretroviral therapy":
. Antiretroviral therapy (ART) is used to treat HIV, but there is no indication that this patient has HIV. The symptoms presented — dyspnea, productive cough, fever, and bilateral consolidation on chest X-ray — are more consistent with an acute bacterial infection such as pneumonia rather than an HIV-related complication. ART would only be appropriate if the patient were known to have HIV and developed an opportunistic infection; however, this patient's presentation suggests a primary respiratory infection, not an HIV-related issue.

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Correct Answer is B

Explanation

A. Sedate the client with PRN medications so they stay in bed:
Sedating a client to prevent movement is not an appropriate intervention for fall prevention. This approach could have adverse effects, such as increased confusion, sedation, and even a greater risk for falls once the medication wears off. It may also contribute to a decreased level of independence and quality of life for the client. Non-pharmacological interventions such as environmental modifications and supportive devices should be prioritized.

B. Implement the bed alarm and call light system:
Implementing a bed alarm and call light system is an effective and appropriate strategy to prevent falls in an older adult client. The bed alarm alerts the healthcare team when the client attempts to get out of bed, reducing the risk of falls. The call light allows the client to request assistance before attempting to move independently, ensuring timely support and reducing fall risk. This intervention promotes safety while maintaining the client’s autonomy.

C. Ensure all four side rails on the bed are up:
While side rails may prevent a client from falling out of bed, raising all four side rails can increase the risk of injury. Clients may try to climb over the rails, which can lead to entrapment or falls. In addition, side rails can create a false sense of security and reduce the client's ability to mobilize independently. A more appropriate measure would be using one or two side rails or providing assistance with repositioning or transferring when necessary.

D. Avoid night lights in the client's room to promote sleep:
Avoiding night lights is not advisable for older adults, particularly those at risk for falls. A dark environment can increase confusion and disorientation, leading to unsafe movements. Providing soft night lights in the room can enhance visibility during nighttime hours, reducing the likelihood of accidents and falls when the client needs to get up to use the bathroom or reposition. Adequate lighting is a key aspect of fall prevention.

A. Check the identifying information on the unit of blood against the patient’s ID bracelet B. Stay with the patient for 60 minutes after starting the transfusion C. Add the blood transfusion as a secondary line to the existing IV. D. Prime new primary IV tubing with lactated Ringer's Solution to use for the transfusion

Correct Answer is A

Explanation

A) Check the identifying information on the unit of blood against the patient’s ID bracelet:
This is the highest priority to ensure patient safety before beginning a transfusion. The risk of transfusion reactions, including hemolytic reactions due to mismatched blood, makes verifying patient identification critical. The nurse must match the blood product with the patient’s information and confirm that the blood product is correct for the patient. This verification is typically done with a second nurse to ensure safety. If the blood is mismatched, it can lead to severe, potentially life-threatening consequences.

B) Stay with the patient for 60 minutes after starting the transfusion:
While it is important to stay with the patient during the transfusion and monitor for adverse reactions, the highest priority before starting the transfusion is verifying patient and blood product compatibility. After starting the transfusion, staying with the patient for the first 15 minutes is critical for monitoring for early signs of a transfusion reaction, but this action occurs after the blood has been correctly matched and started.

C) Add the blood transfusion as a secondary line to the existing IV:
Ensuring proper identification and blood product matching is more critical than deciding whether to use a secondary IV line. The nurse should verify patient and blood compatibility first and then proceed with setting up the IV line for transfusion.

D) Prime new primary IV tubing with lactated Ringer's solution to use for the transfusion:
Priming IV tubing with lactated Ringer’s solution is incorrect for a blood transfusion. Blood should only be administered with normal saline, as other fluids, including lactated Ringer's solution, can cause clotting or hemolysis when mixed with blood products. This action would not be a safe or appropriate step in preparing for a blood transfusion. The correct solution to prime tubing for blood transfusions is normal saline, and this is secondary to ensuring proper patient identification and blood compatibility.

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An older adult client presents with dyspnea on exertion, cough with green sputum, fever, and fatigue. The nurse notes thick rhonchi/coarse crackles upon lung auscultation and the patient's chest X-ray shows bilateral consolidation. The nurse anticipates which of the following interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an older adult client who is at risk for falls. Which of the following interventions should be included in the plan of care for this client?

Correct Answer is B

Explanation

Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to ensure patient safety?

Correct Answer is A

Explanation

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