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 involves the patient sitting or standing with their hands on their knees or a table, which helps in optimizing lung expansion and improving breathing. This position can help clients with COPD ease their breathing by increasing the use of accessory muscles and allowing the diaphragm to work more efficiently.
B) Restrict the client's fluid intake to less than 2 L/day: Restricting fluid intake is generally not recommended for COPD patients unless there are specific signs of fluid retention or other contraindications. Adequate fluid intake is important to keep mucus thin and easier to expel. Restricting fluids may worsen mucus thickness and make it harder to clear secretions.
C) Provide the client with a low-protein diet: COPD patients often need a higher-protein diet to help maintain muscle mass and support overall nutritional status. A low-protein diet would not be appropriate as it could lead to muscle wasting and decreased respiratory muscle strength.
D) Have the client use the early-morning hours for exercise and activity: While physical activity is important, the timing of exercise should be tailored to the client's individual tolerance and condition. Early-morning exercise might not be suitable for all patients, especially if they experience morning respiratory symptoms or have other considerations. The key is to find an optimal time that aligns with the patient's energy levels and condition.

A. Vagus B. Facial C. Glossopharygeal D. Trigeminal

Correct Answer is D

Explanation

A. Vagus: The vagus nerve (cranial nerve X) is involved in regulating autonomic functions, such as heart rate and digestion. It does not play a significant role in controlling jaw movements or clenching.
B. Facial: The facial nerve (cranial nerve VII) controls facial expressions, such as smiling or frowning, and also contributes to taste sensation in the anterior two-thirds of the tongue. While it is related to facial motor function, it does not control the jaw muscles responsible for clenching.
C. Glossopharyngeal: The glossopharyngeal nerve (cranial nerve IX) is involved in taste sensation on the posterior one-third of the tongue, as well as in swallowing and salivation. It does not control the jaw muscles used for clenching.
D. Trigeminal: The trigeminal nerve (cranial nerve V) is responsible for sensation in the face and motor functions related to chewing. It innervates the muscles of mastication, including those involved in clenching the jaw. The client’s jaw clenching is a direct manifestation of motor function associated with the trigeminal nerve.

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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 54 year-old client diagnosed with Bipolar disorder is clenching his jaw closed to avoid taking a prescribed oral medication. The nurse can use this observation to confirm the client is demonstrating motor function of which cranial nerve?

Correct Answer is D

Explanation

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