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 the most therapeutic response because it shows respect for the client’s autonomy and allows the nurse to explore the client’s concerns and feelings about the medication.
It also helps to establish trust and rapport with the client. Choice B. Report refusal to the charge nurse.
This is wrong because it does not address the client’s immediate needs and may make the client feel ignored or dismissed.
Choice C. Explain the purpose of the medication.
This is wrong because it may sound like lecturing or persuading the client, which can increase resistance and hostility.
Choice D. Encourage the client to take the medication.
This is wrong because it does not acknowledge the client’s right to refuse treatment and may imply that the nurse knows better than the client what is best for them.
Correct Answer is A
Explanation
A toileting routine is the priority intervention for a client diagnosed with total urinary incontinence because it helps to prevent skin breakdown, infection, and odor. It also promotes dignity and comfort for the client.
Choice B. Kegel exercises are wrong because they are not effective for total urinary incontinence, which is the complete loss of bladder control. Kegel exercises are more useful for stress or urge urinary incontinence, which are caused by weak pelvic floor muscles.
Choice C. Surgery is wrong because it is not a priority intervention for total urinary incontinence.
Surgery may be considered a last resort option if other conservative measures fail to improve the condition. Surgery may also have risks and complications that need to be weighed against the benefits.
Choice D. Anticholinergic drug therapy is wrong because it is not a priority intervention for total urinary incontinence.
Anticholinergic drugs are used to treat overactive bladder or urge urinary incontinence, which are caused by involuntary bladder contractions. Anticholinergic drugs may have side effects such as dry mouth, constipation, blurred vision, and confusion.
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