The nurse is obtaining morning vital signs and assessing a 64 year old female client who was admitted with community acquired pneumonia over night. The client is sleeping in supine position, however, she is easily arousable, alert and oriented, and reports no complaints at this time. The client's vital signs are: blood pressure 132/68, heart rate 88 beats per minute, respiratory rate 24 breaths per minute. O2 saturation 87% on 2L nasal cannula oxygen. What is the nurse's first priority action?

Begin oxygen via face mask at 5L/min

Call the physician and report vital signs

Raise the head of the bed

Administer albuterol nebulizer as ordered

Answer and Explanation

The Correct Answer is C

A.   Increasing oxygen via face mask may be necessary, but raising the head of the bed is the initial priority to improve oxygenation.
B.   Reporting vital signs is important, but immediate intervention is needed to address the low oxygen saturation.
C. Raising the head of the bed helps improve lung expansion and oxygenation in pneumonia patients by reducing pressure on the diaphragm.
D.   Administering albuterol may be part of the plan, but improving the client's position is the immediate priority.

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Correct Answer is C

Explanation

A. Identifying each other by name and providing orientation to the healthcare system are typically actions in the orientation phase, not the termination phase.
B. Clarifying roles and establishing an agreement about the relationship are more relevant to the orientation phase.
C. The termination phase involves determining if patient goals have been met and making suggestions for future needs after discharge.
D. Working together to meet the patient's needs and providing teaching and counseling are aspects of the working phase.

A. Do not allow the patient food choices and reinforce the importance of eating exactly what is delivered on the tray. B. Assess for pain after meals and only administer pain medication when patient is completely done eating. C. Inquire about patient food preferences and serve small frequent meals. D. Serve large portion meals 3 times a day around scheduled procedures.

Correct Answer is C

Explanation

A. Allowing food choices and accommodating preferences can help stimulate appetite and improve nutritional intake.
B. Assessing for pain is important, but withholding pain medication until after meals is not conducive to improving appetite.
C. Inquiring about food preferences and serving small, frequent meals can be more appealing and help stimulate appetite.
D. Serving large portion meals may be overwhelming for a patient with a reduced appetite and may not be effective in improving intake.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a patient who is hospitalized following a right knee replacement is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship?

Correct Answer is C

Explanation

A patient with a respiratory disease of COPD is refusing to eat. Which action by the nurse would be most helpful in stimulating appetite in this patient?

Correct Answer is C

Explanation

A client is ordered to increase his warfarin to 5mg PO daily. The client has 2mg tablets on hand. How many tablets will the client take daily?

The client is complaining of soreness around the stoma site. The nurse notes proper drainage in the bag, however, the surrounding skin is red, irritated, and moist. How will the nurse interpret this assessment?

A nurse is feeding a patient who is experiencing dysphagia and requires thickened liquids to prevent from aspirating. Which nursing consideration would be a priority for the nurse to initiate while feeding this patient on a dysphagia diet with thickened liquids?

For which of the following clients should the nurse anticipate the need for a pureed diet?

In caring for a client experiencing acute hypoxia, the nurse should prepare interventions to help the client for what other condition?

A nurse is providing instruction to a client who will be performing a 24 hour urine collection at home. Which of the following instructions will the nurse give the client?