The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?

Initiate droplet precautions

Initiate airborne precautions

Place the client in a positive pressure room

Initiate neutropenic precautions

Answer and Explanation

The Correct Answer is B

B. Airborne precautions are used for diseases that can be transmitted through tiny respiratory droplets that remain in the air for extended periods. Examples include tuberculosis and measles. Given the symptom of coughing up blood and the possibility of an infectious respiratory disease, initiating airborne precautions could be warranted.
A. Droplet precautions are typically implemented for diseases that spread through respiratory droplets, such as influenza or pertussis. However, coughing up blood suggests a more serious condition that may not be adequately addressed by droplet precautions alone.
C. Positive pressure rooms are typically used in healthcare settings to prevent outside air from entering the room, thus reducing the risk of airborne contaminants. While this measure can be beneficial for certain conditions, such as those requiring airborne precautions, it may not be the priority intervention.
D. Neutropenic precautions are implemented for patients with compromised immune systems, particularly those with low white blood cell counts (neutropenia). While this precaution is important for protecting immunocompromised patients from infections, it may not be the priority intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

C. Individuals with borderline personality disorder often struggle with intense emotions and may engage in self-harming behaviors as a maladaptive coping mechanism. Helping the client identify triggers for their distress and teaching them alternative coping strategies, such as mindfulness, grounding techniques, or distress tolerance skills, can empower them to manage their emotions in healthier ways.
A. Anxiolytic medications can help alleviate anxiety symptoms but they are not typically the first-line intervention for addressing acute distress in individuals with borderline personality disorder (BPD).
B. Restraint should not be the first response to a client expressing distress or suicidal ideation. Physical restraint should only be used as a last resort in situations where there is an imminent risk of harm to the client or others and should be implemented by trained professionals following established protocols.
D. Encouraging self-harm behaviors reinforces maladaptive coping strategies and can increase the risk of harm to the client. It is essential to provide support and interventions aimed at reducing self-harming behaviors.

A. call for emergency assistance from other staff. B. take him to a room with toys to act out feelings. C. tell the boy's mother to take him home immediately. D. direct him to stop, then confront the other child.

Correct Answer is B

Explanation

B. Providing a safe and supportive environment for the child to express and manage their emotions is important. Taking the child to a room with toys allows them to engage in play and express their feelings in a constructive manner.
A. Emergency assistance from other staff would typically be reserved for situations posing immediate danger to the child or others, which may not be the case here.
C. Sending the child home immediately could be seen as a punitive measure and may not contribute to the child's understanding of the behavior's impact.
D. Directing the child to stop the behavior and then confronting the other child may escalate the situation and potentially lead to further conflict or aggression.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is assessing a newly admitted client whose chief complaint is "coughing up blood" and whose recent history includes a productive cough and night sweats. What is the nurse's priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:

Correct Answer is C

Explanation

The best action for the nurse to take with a 5-year-old who runs over to another child in the waiting room and slaps her is to:

Correct Answer is B

Explanation

The nurse is educating clients about recovery from alcohol abuse. Which statement indicates that learning has occurred?

Which predisposing factor obtained during the nursing assessment would cause the nurse to consider a child to be at risk for the development of a psychiatric disorder?

The nurse is administering furosemide 40 mg PO to a client who has peripheral edema. Which method would the nurse use to best evaluate the client's response to this medication?

During a routine health examination, the client tells the nurse about using a variety of herbal therapies for health maintenance. When discussing the use of herbs, the nurse cautions the client that: (SELECT ALL THAT APPLY)

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

A severely depressed, sullen client has been taking fluoxetine for 10 days. During the first outpatient visit, the client smiles excitedly and states, "I feel so much better now." How should the nurse interpret this behavior change? The:

A client is seen in the Emergency Department (ED) following a motor vehicle accident. The client's blood alcohol level (BAL) is 0.11 g/dL. The nurse assesses that this client:

An individual with a history of antisocial personality disorder was arrested for driving under the influence of alcohol and causing a serious car accident. Which comment on this behavior would be expected?