The nurse receives a telephone prescription from the healthcare provider for a client's persistent cough and wheezing. The prescription includes a chest x-ray, an antibiotic, and a nebulizer treatment now and as needed (PRN). After reading the prescription back to the healthcare provider to ensure accuracy, which intervention should the nurse implement first?

Apply portable oxygen for transport to radiology.

Administer a nebulizer breathing treatment.

Evaluate breathing pattern.

Start the prescribed antibiotic.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Applying portable oxygen for transport to radiology is not the first priority. The immediate concern is assessing and addressing the client's respiratory distress before initiating specific interventions.

Choice B rationale: The nebulizer treatment should be administered FIRST to alleviate the clients obstructed airway (respiratory distress)

Choice C rationale: Evaluating the breathing pattern is important but should be done immediately after implementing physician orders

Choice D rationale: Starting the prescribed antibiotic is not the first priority. Respiratory assessment takes precedence to address the client's immediate distress.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. Remind the UAP to apply a fitted respirator mask before entering the client's room: A fitted respirator (N95 mask) is used for airborne precautions (e.g., tuberculosis), not droplet precautions like influenza.
B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status: This is beyond the UAP’s scope of practice. Assessment and clinical judgment are the nurse’s responsibility.
C. Assign the UAP to provide care for another client and assume full care of the client: There is no indication that the UAP is incapable of providing care once properly instructed in precautions.
D. Review the need for the UAP to wear a face mask while in close contact with the client: Influenza is spread via respiratory droplets, so a surgical mask is required when within 3 feet of the client. This action ensures appropriate use of personal protective equipment (PPE).

A. Ask the nurse to explain thoughts on the need for an Inservice program about these emergencies. B. Choose to send another nurse who is more receptive and interested in the topic. C. Encourage the nurse to share concerns and discuss ways to prepare for such emergencies. D. Inform the nurse that in-service is not optional and attendance is mandatory.

Correct Answer is C

Explanation

Choice A rationale: Asking the nurse to explain thoughts on the need for an in-service program encourages open communication and allows the nurse-manager to address specific concerns.

Choice B rationale: Choosing to send another nurse may not address the concerns of the nurse expressing dissatisfaction and may not promote a collaborative approach. Choice C rationale: Encouraging the nurse to share concerns and discuss ways to prepare for emergencies fosters open communication and allows for constructive dialogue.

Choice D rationale: Informing the nurse that in-service is not optional and attendance is mandatory may create resistance and does not promote a collaborative approach to addressing concerns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with influenza is admitted to the medical unit. The nurse observes an unlicensed assistive personnel (UAP) preparing to enter the client's room to take vital signs and assist with personal care. The UAP has applied gloves and a gown. Which action should the nurse take?

Correct Answer is D

Explanation

The nurse-manager overhears a nurse complaining to a co-worker about the time being required to attend an in-service session for bioterrorism preparedness. How should the nurse-manager respond?

Correct Answer is C

Explanation

The nurse receives change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?

A client with life threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?

It is most important to assign which client to a registered nurse rather than a practical nurse (PN)?

While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?

An adult client is admitted via the emergency department (ED) with a head injury that will initially require intensive care. Which nurse should be responsible for coordinating the progression of this client's care through rehabilitation and discharge?

A nurse is performing telephone triage at the clinic office. Which client has the most acute problem and should be scheduled for the first available appointment?