The nurse is assigned to care for two critical care clients. One client was admitted yesterday with pneumonia, is being mechanically ventilated and has an elevated temperature. The other client had a thoracotomy two days ago and is now complaining of incisional pain. Which intervention should the nurse implement first?

Assess level of consciousness and vital signs for both clients.

Administered pain medication to the client with incisional discomfort.

Complete a head-to-toe physical assessment for the client with pneumonia.

Review the plan of care and the medications for both clients.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Assess level of consciousness and vital signs for both clients: This action prioritizes airway, breathing, and circulation (ABCs) and ensures prompt identification of any deterioration in either client's condition. It provides critical data needed to safely proceed with further interventions such as administering medications or conducting full assessments.

B. Administered pain medication to the client with incisional discomfort: While pain management is important, it is not the priority over initial assessment of both clients' status—especially the one on mechanical ventilation with an elevated temperature.

C. Complete a head-to-toe physical assessment for the client with pneumonia: A full assessment is essential, but it is not the most immediate action. Checking vital signs and neurological status first can quickly reveal urgent issues that might require rapid intervention.

D. Review the plan of care and the medications for both clients: This is necessary but should be done after determining the clients’ current conditions. Immediate physiological assessment takes precedence in critical care settings to prevent delays in interventions.

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Correct Answer is C

Explanation

Rationale:

A. Manages activities of daily living independently: Preserving functional independence is not a direct clinical outcome related to managing chronic pyelonephritis. The primary concern with this condition is preserving renal function and preventing long-term complications like hypertension.

B. Measures oral temperature daily: Monitoring temperature can help detect infections early, but chronic pyelonephritis may not always present with fever. It’s a short-term strategy and less critical than preventing progression to renal damage or cardiovascular complications.

C. Maintains blood pressure within normal limits: Chronic pyelonephritis can lead to kidney scarring, which often contributes to secondary hypertension. Controlling blood pressure is vital in slowing renal deterioration and preventing cardiovascular events, making it the most important long-term goal.

D. Restricts fluid intake to 1 L/day: Fluid restriction is not appropriate unless the client is in advanced kidney failure with fluid overload. Adequate hydration is usually encouraged to help flush bacteria from the urinary tract and support renal function.

A. Report the COVID-19 result to the local health department according to the Center for Disease Control (CDC) guidelines. B. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). C. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility. D. Place the nasal swab specimen for COVID-19 directly into a biohazard bag.

Correct Answer is B

Explanation

Rationale:
A. Report the COVID-19 result to the local health department according to the Center for Disease Control (CDC) guidelines: Reporting is important for public health surveillance but is not the nurse’s most immediate priority. Isolation should occur first to prevent the spread of infection, especially before confirmatory test results are available.

B. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE): Prompt isolation is the highest priority to prevent transmission of COVID-19. Even with a previous negative test, current symptoms suggest active infection, and precautions must be implemented immediately to protect others.

C. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility: While communication with the charge nurse is necessary for client placement, it should follow immediate implementation of infection control measures.

D. Place the nasal swab specimen for COVID-19 directly into a biohazard bag: Proper specimen handling is critical for safety and test integrity but does not take precedence over isolating a potentially infectious client.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which long-term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis?

Correct Answer is C

Explanation

Four days after exposure to COVID-19 a client has a negative COVID-19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

The nurse is reviewing a pregnant client's prenatal immunization history. Which immunization should the nurse instruct the client to receive after pregnancy?

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