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 C
Explanation
The correct answer is choiceC. Health care proxy documentation.
Choice A rationale:
The name of the funeral home to contact is not immediately relevant during the admission assessment of a terminally ill client. This information can be collected later as part of end-of-life planning but is not critical for the initial assessment.
Choice B rationale:
While the contact information for the client’s next of kin is important for communication and support, it is not as crucial as health care proxy documentation for making immediate healthcare decisions.
Choice C rationale:
Health care proxy documentation is essential because it designates someone to make healthcare decisions on behalf of the client if they become unable to do so themselves.This ensures that the client’s healthcare preferences and decisions are respected and followed by the healthcare team.
Choice D rationale:
The client’s wishes regarding organ donation are important but are often included in the health care proxy documentation.This information is not as immediately critical as the health care proxy documentation during the admission assessment.
Correct Answer is D
Explanation
Determine the client's usual bowel pattern.
Choice A rationale:
Administering a prescribed PRN stool softener may be necessary if the client is experiencing constipation, but it is not the first action the PN should implement. Before administering any medication, the PN should gather more information to make an informed decision.
Choice B rationale:
Encouraging the client to ambulate more frequently can be beneficial for promoting bowel movements, but it is not the first action to implement. The PN should first assess the client's bowel pattern to determine if there is a deviation from their usual routine.
Choice C rationale:
Recommending increasing high fiber foods daily can also help with constipation, but it is not the first action to take. The PN should assess the client's current bowel pattern to better understand the situation.
Choice D rationale:
Determining the client's usual bowel pattern is the first action the PN should take. This assessment will help establish a baseline and identify any deviations that might indicate a potential issue, which can then guide further interventions.
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