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","C"]
Explanation
Choice A is correct because using a soft toothbrush can decrease the risk of bleeding from the gums, which is a common site of bleeding for people with hemophilia.
Choice C is correct because reporting excessive bleeding to the provider and using precautions to protect the head and joints are important aspects of home care for hemophilia.
Choice B is wrong because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can interfere with platelet function and increase bleeding tendency. People with hemophilia should avoid NSAIDs and use acetaminophen instead for pain relief.
Choice D is wrong because clotting factor treatments are not only needed when a bleed occurs but also as a preventive measure to reduce the frequency and severity of bleeding episodes. People with severe hemophilia need regular clotting factor replacement therapy for the rest of their lives.
Choice E is wrong because warm, painful joints are signs of joint bleeding, which is a serious complication of hemophilia that can lead to permanent joint damage.
People with hemophilia should not apply heat to their joints, but rather use ice packs, compression, elevation and rest to reduce swelling and pain. They should also seek medical attention and receive clotting factor replacement therapy as soon as possible.
Correct Answer is A
Explanation
A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.
The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.
Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.
Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.
The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.
Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.
Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.
The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.
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