The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?

Risk for infection

Ineffective airway clearance

Acute pain

Disturbed body image

Answer and Explanation

The Correct Answer is B

The correct answer is choice B. Ineffective airway clearance.

Choice A rationale:

Risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.

Choice B rationale:

Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.

Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.

Choice C rationale:

Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.

Choice D rationale:

Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.

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Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Enrolling the UAP in a hospital education class on conducting safe client care is not an immediate response and does not address the current situation. It may be a longer-term solution for ongoing education.

Choice B rationale: Praising the UAP for performing oral hygiene and encouraging family participation does not address the immediate safety concern of the procedure being performed correctly.

Choice C rationale: Telling the UAP to continue because the unconscious client is positioned safely is incorrect. The client should not be in a flat side-lying position as it increases the risk of aspiration during oral hygiene.

Choice D rationale: Stopping the procedure and telling the UAP to place the client in a Fowler's position is correct. The Fowler's position helps maintain an open airway and reduces the risk of aspiration during oral hygiene in an unconscious client.

A. Explain the occurrence to the client. B. Observe the appearance of the injection site. C. Call the charge nurse to the room. D. Cleanse the finger with soap and water.

Correct Answer is D

Explanation

The correct answer is choice D. Cleanse the finger with soap and water.

Choice A rationale:

Explaining the occurrence to the client is not the first action the PN should take in this situation. The priority is to address the potential exposure to bloodborne pathogens and ensure the PN's safety.

Choice B rationale:

Observing the appearance of the injection site is important for routine assessment but is not the first action the PN should take after getting stuck with the used needle. Immediate action to clean the wound site is essential to reduce the risk of infection.

Choice C rationale:

While notifying the charge nurse about the incident is important, it should not be the first action taken. The PN's safety should be addressed first by cleansing the finger.

Choice D rationale:

The PN should first cleanse the finger with soap and water immediately after getting stuck with the used needle. This action helps reduce the risk of infection and contamination. After cleansing, the PN can follow the facility's protocol for reporting incidents and seek necessary medical attention if required.

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The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take?

Correct Answer is D

Explanation

The practical nurse (PN) administers an injection using a syringe with a retractable needle. After the needle is removed from the client's skin, the needle does not retract, and the PN gets stuck in the finger with the used needle. What action should the PN take first?

Correct Answer is D

Explanation

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