The nurse reviews the healthcare provider’s orders for a client with bacterial pneumonia. Which of the following should the nurse carry out first?
Obtain a sputum culture specimen.
Administer azithromycin 500mg IVPB.
Encourage coughing and deep breathing.
Offer clear liquids for the client to drink.
The Correct Answer is A
The nurse should obtain a sputum culture specimen before administering any antibiotics to the client with bacterial pneumonia.
This is because the sputum culture can help identify the causative organism and the appropriate antibiotic therapy.
Administering antibiotics before obtaining the sputum culture can alter the results and lead to ineffective treatment.
Choice B is wrong because azithromycin is an antibiotic that should be given after obtaining the sputum culture.
Choice C is wrong because coughing and deep breathing are important interventions to promote airway clearance and gas exchange, but they are not the priority actions for this client.
Choice D is wrong because offering clear liquids can help prevent dehydration and thin secretions, but they are not the most urgent action for this client.
Normal ranges for blood urea nitrogen (BUN) are 7 to 20 mg/dL and for creatinine are 0.6 to
1.2 mg/dL.
Elevated levels of these substances can indicate renal impairment, which can be a complication of bacterial pneumonia.
The nurse should monitor these levels and report any abnormalities to the health care provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because aspirin can cause gastrointestinal bleeding, ulceration, and perforation as side effects. Tarry-colored stools indicate the presence of blood in the stool, which is a sign of bleeding in the upper gastrointestinal tract.
This is a serious condition that requires immediate medical attention.
Choice B. Swelling of the leg and knee is wrong because it is not related to aspirin use.
It may indicate inflammation, infection, or injury of the leg and knee, but it is not a priority symptom to report to the HCP.
Choice C. Right upper quadrant discomfort is wrong because it is not related to aspirin use.
It may indicate liver or gallbladder problems, but it is not a priority symptom to report to the HCP.
Choice D. Bruising around the injured knee is wrong because it is not related to aspirin use.
It may indicate trauma, bleeding disorders, or coagulation problems, but it is not a priority symptom to report to the HCP.
Normal ranges for bleeding time are 2 to 7 minutes. Normal ranges for PTT are 25 to 35 seconds. Normal ranges for liver enzymes are AST 10 to 40 U/L and ALT 7 to 56 U/L.
Correct Answer is B
Explanation
This is because itching is a subjective assessment finding, which means it is based on the personal experience, view or feeling of the
patient. The other choices are objective assessment findings, which means they are based on observable or measurable data that the nurse can collect.
For example:
Choice A is wrong because hives are a visible skin reaction that can be seen and measured by the nurse.
Choice C is wrong because vomiting is an observable action that can be verified and recorded by the nurse.
Choice D is wrong because abdominal distension is a measurable change in the size or shape of the abdomen that can be assessed by the nurse.
Normal ranges for objective assessment findings may vary depending on the source and context, but some possible examples are:
- Hives: No hives or rashes on the skin are normal.
- Vomiting: No vomiting or nausea are normal.
- Abdominal distension: Normal abdominal girth for adults ranges from 68 to 100 cm (27 to 40 inches).
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