The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Implement an intervention.

Perform an assessment

Develop a nursing diagnosis.

Evaluate an outcome.

Answer and Explanation

The Correct Answer is D

A) Implement an intervention: Implementing an intervention is part of the nursing process, but in this context, administering an antipyretic is already an action that has been taken. The next step after implementing an intervention is to assess the outcome of that intervention.
B) Perform an assessment: Performing an assessment is crucial for gathering initial data and identifying problems. However, after administering an antipyretic, the next logical step is to evaluate the effectiveness of that intervention, not to perform an initial assessment.
C) Develop a nursing diagnosis: Developing a nursing diagnosis is part of the process used to identify patient problems based on the assessment data. Since the antipyretic has already been administered, the focus should now be on evaluating the effectiveness of this action rather than creating a new diagnosis.
D) Evaluate an outcome: Evaluating an outcome is the appropriate next step after administering an intervention like an antipyretic. The nurse should assess whether the medication has effectively reduced the fever, improved the client's condition, or resulted in any changes in vital signs. This step helps determine if the intervention was successful and guides further care planning.

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Correct Answer is A

Explanation

A) Instruct the patient on Tripod positioning: Tripod positioning, where the patient leans forward with hands on their knees or a table, is beneficial for COPD patients. It helps improve ventilation by allowing the diaphragm to work more efficiently and aiding in the expansion of the lungs. This position also utilizes accessory muscles, which can help ease breathing and reduce the work of respiration.
B) Restrict the client's fluid intake to less than 2 L/day: Restricting fluid intake is generally not advisable for COPD patients unless there is a specific condition such as severe heart failure where fluid restriction is necessary. Adequate fluid intake helps to thin mucus, making it easier to expectorate and thus supports better lung function and overall respiratory health.
C) Provide the client with a low-protein diet: COPD patients typically require a higher-protein diet to maintain muscle mass and strength, which are crucial for overall health and respiratory function. A low-protein diet can lead to muscle wasting, including the respiratory muscles, which can worsen respiratory symptoms and functional status.
D) Have the client use the early-morning hours for exercise and activity: While regular exercise is important, the timing should be based on the client's individual preferences and tolerance. For some patients, early morning might not be the best time due to morning symptoms or fatigue. The exercise plan should be customized to fit the patient’s daily routine and energy levels.

A. this is an abnormal breath sound due to bronchial airways being narrowed, bronchoconstriction B. this is a normal breath sound due to normal gas exchanged C. this is an abnormal breath sound due to bronchial airways being dilated, bronchodilation D. this is a normal breath sound due to the alveoli being fluid-filled

Correct Answer is A

Explanation

A) This is an abnormal breath sound due to bronchial airways being narrowed, bronchoconstriction: Wheezing is an abnormal breath sound characterized by a high-pitched whistling noise produced during breathing. It occurs when the bronchial airways are narrowed due to bronchoconstriction, inflammation, or mucus, common in conditions like asthma. This narrowing of the airways creates turbulent airflow, leading to the wheezing sound.

B) This is a normal breath sound due to normal gas exchange: Wheezing is not a normal breath sound and is indicative of an obstruction or narrowing in the airways. Normal breath sounds, such as vesicular breath sounds, are smooth and do not include wheezing.

C) This is an abnormal breath sound due to bronchial airways being dilated, bronchodilation: Wheezing results from airway narrowing, not dilation. Bronchodilation, which is the widening of the airways, would typically reduce or resolve wheezing rather than cause it.

D) This is a normal breath sound due to the alveoli being fluid-filled: Wheezing is related to airway narrowing rather than fluid in the alveoli. Fluid in the alveoli would more commonly cause crackles or rales, not wheezing.

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The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Correct Answer is A

Explanation

A nursing student asked the respiratory floor nurse why the adventitious wheezing breath sounds are present in asthmatic patients. The nurse should respond:

Correct Answer is A

Explanation

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