The practical nurse (PN) notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8°F (37.66°C); pulse 94; respirations 22; and blood pressure (BP) 108/54. Which intervention is most important for the PN to implement?
Monitor the client's temperature hourly.
Offer the client fluids frequently.
Provide care to moisten oral mucosa.
Report the findings to the charge nurse.
The Correct Answer is D
Correct Answer: D. Report the findings to the charge nurse.
Choice A rationale:
Monitoring the client's temperature hourly may be indicated if the client's condition deteriorates or if there are specific concerns about fever. However, the temperature of 99.8°F (37.66°C) is not significantly elevated and may not be the primary concern in this situation.
Choice B rationale:
Offering the client fluids frequently is a good nursing practice, but it is not the most important intervention in this case. The client's nonproductive cough and increased confusion need to be addressed and reported first.
Choice C rationale:
Providing care to moisten oral mucosa is important for maintaining oral health and preventing dryness and discomfort. However, it may not directly address the client's current symptoms of cough and confusion.
Choice D rationale:
Reporting the findings to the charge nurse is the most crucial intervention. The client's nonproductive cough and increased confusion may be indicative of an underlying issue, such as a respiratory infection or a change in neurological status. The charge nurse can initiate further assessments, notify the healthcare provider, and implement appropriate interventions to address the client's condition promptly. Timely reporting and communication are essential to ensure the client receives appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is D
Explanation
The correct answer is
Choice D rationale:
The practical nurse (PN) should review the client's risk factors for exercise intolerance that impact his quality of life. By doing so, the PN can assess the client's overall health and identify any potential issues that might contribute to his fatigue. This response shows the PN's concern for the client's well-being and is focused on exploring the root cause of his tiredness.
Choice A rationale:
Determining if the client can move to a residential home without lawn maintenance is not appropriate in response to his complaint about feeling tired. This option does not address the underlying issue and assumes the client is unable to care for his own lawn, which may not be the case.
Choice B rationale:
Recommending that the client retires from doing outdoor chores is also not appropriate. It assumes the client's fatigue is solely due to his age and disregards the possibility of other contributing factors that might be addressed.
Choice C rationale:
Advising the client that fatigue is a common characteristic of aging is not a comprehensive response. While fatigue can be related to aging, it is crucial to explore the specific reasons for the client's tiredness before assuming it is solely age-related.
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