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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
The correct answer is choice D. Don non-sterile gloves when performing direct care.
Choice A rationale:
Placing a surgical mask on the client during transport is not necessary for preventing the spread of Clostridium difficile. C. difficile is primarily spread through contact with contaminated surfaces and not through airborne transmission.
Choice B rationale:
Keeping the door closed to the client’s room at all times is not required for C. difficile infection. The focus should be on contact precautions rather than airborne precautions.
Choice C rationale:
Wearing a particulate respirator mask is not needed for C. difficile, as it is not an airborne pathogen. Standard contact precautions are sufficient.
Choice D rationale:
Donning non-sterile gloves when performing direct care is essential to prevent the spread of C. difficile. The spores can be transmitted via the hands of healthcare workers, so wearing gloves helps to minimize this risk.
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