When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Provide a box of tissues for the client to use when coughing.

Assist the client in changing into a fresh hospital gown.

Teach the client to cover the mouth with hands when coughing.

Obtain face masks for staff to wear upon entering the room.

Answer and Explanation

The Correct Answer is A

A. Providing tissues is a helpful measure for clients to use when they need to cough or sneeze. It promotes good hygiene by allowing the client to dispose of respiratory secretions properly. However, this choice does not address the immediate concern of how the client is currently coughing and the potential for spreading infection.
B. Assisting the client with a gown change may be necessary if their current gown is soiled. However, this action does not directly address the infection control issue or the client’s method of coughing. Changing the gown is secondary to addressing proper coughing techniques and infection control.
C. Teaching clients to cover their mouth with their hands is not ideal, as it can spread germs if the hands are not washed immediately afterward. Instead, clients should be taught to cough into a tissue or their elbow (not the sleeve) to minimize the spread of germs. This is a crucial component of infection control and helps reduce the risk of transmission.
D. Providing face masks for staff is an important measure in infection control, especially if the client has a respiratory illness. However, it does not address the client's current coughing technique or teach the client how to prevent the spread of infection through their own actions.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. This can strain the back and increase the risk of injury. It's important to use proper body mechanics, such as bending the knees and keeping the back straight, when reaching for objects.
B. Bending at the waist can strain the back and increase the risk of injury. It's important to lift objects with the legs, not the back.
C. This can strain the back and hips. It's important to use proper body mechanics, such as using the legs and core muscles to push or pull heavy objects.
D. Standing erect with knees bent provides a strong base of support and helps to distribute weight evenly. Bending the knees allows for lifting with the legs, which is less stressful on the back and reduces the risk of injury. Pulling a draw sheet and moving a client in bed requires a combination of strength and proper body mechanics. Standing erect with knees bent helps to prevent strain on the back and muscles

A. Determine which member of the nursing staff brought the cup of coffee to the client. B. Consult with the dietician to learn if the client is allowed to drink coffee. C. Remove the coffee from the tray, advising the client that it is not included in the diet. D. Remind the client that no milk or creamer can be added to the coffee.

Correct Answer is C

Explanation

A. While it’s important to understand how the coffee ended up on the tray, determining which staff member made the mistake does not address the immediate issue of ensuring the client’s diet is appropriate. The priority should be to correct the dietary error and ensure that the client receives only what is appropriate for their diet.
B. Consulting with a dietician could provide clarity on dietary restrictions and allowances. However, if the client is on a clear liquid diet, coffee is typically not included because it may have additives (like milk or creamer) or may not be considered suitable for the clear liquid diet.
C. Coffee, unless specified as permissible, generally does not meet the criteria for a clear liquid diet due to its potential to be mixed with non-clear substances and its stimulant properties. Removing the coffee and informing the client of the dietary restriction ensures that the client adheres to the prescribed diet and avoids potential complications or issues with their treatment.
D. This action is not suitable for a clear liquid diet. Coffee itself is typically not allowed on a clear liquid diet, regardless of whether milk or creamer is added. This choice does not address the fundamental issue of the coffee being inappropriate for the client’s diet.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

Correct Answer is D

Explanation

The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?

Correct Answer is C

Explanation

An older adult client residing in a long-term care facility has become disoriented and suddenly develops urinary incontinence. Which intervention should the nurse implement?

A male client tells the nurse that he is taking large doses of a fish oil supplement to lower his triglyceride level. Which action should the nurse take?

A client in the outpatient clinic reports experiencing hard, infrequent stools. Which instruction should the nurse provide this client?

In assisting the family of an older adult client to determine the best living environment for the client, which factor is most important for the nurse to consider?

The nurse identifies the hospitalized client in which situation as being at highest risk for the development of a healthcare associated infection (HAI)?

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?