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.

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

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

Answer and Explanation

The Correct Answer is A

Choice A reason: Providing tissues encourages proper cough etiquette, reducing droplet spread from a non-productive cough. Coughing into a sleeve is less effective than tissue use, which contains respiratory secretions. This aligns with infection control, minimizing transmission risk in healthcare settings, per CDC respiratory hygiene guidelines.

Choice B reason: Changing the gown is unnecessary, as coughing into the sleeve does not confirm contamination. Tissues better address infection control by containing secretions. Gown changes are resource-intensive and unwarranted without evidence of soiling, per principles of infection prevention and resource management in nursing care.

Choice C reason: Obtaining face masks for staff assumes an infectious condition without evidence. A non-productive cough into the sleeve poses low transmission risk. Tissues promote better hygiene, while masks are excessive unless infection is confirmed, per infection control and evidence-based practice in respiratory care.

Choice D reason: Teaching to cover the mouth with hands is incorrect, as hands spread germs via contact. Tissues or elbow coughing is preferred to reduce transmission. This contradicts infection control principles, risking cross-contamination in healthcare settings, per CDC guidelines on respiratory hygiene and cough etiquette.

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Correct Answer is C

Explanation

Choice A reason: Determining outcome realism is relevant but follows data collection. Evaluation requires comparing current client status (e.g., vital signs, symptoms) to expected outcomes to assess progress. Without data, realism cannot be judged. Data reflects physiological changes, like improved oxygenation, guiding whether outcomes are achievable, making this a secondary step.

Choice B reason: Modifying interventions occurs after evaluating effectiveness, not immediately after reviewing outcomes. Current data (e.g., blood pressure, pain level) must be compared to expected outcomes to determine if interventions succeeded. Premature modification risks inappropriate changes, as physiological or functional status must first confirm the need for adjustment.

Choice C reason: Obtaining current client data is the next step, as evaluation compares actual client status to expected outcomes. Data (e.g., lab results, mobility) reflect physiological or functional changes, indicating intervention success. This step quantifies progress, like reduced edema or improved strength, ensuring evidence-based assessment before adjusting the care plan, making it correct.

Choice D reason: Reviewing professional standards is important for care quality but not the immediate next step in evaluation. Comparing current data to expected outcomes assesses intervention effectiveness, using measurable indicators like glucose levels or wound healing. Standards guide practice but are secondary to data-driven evaluation of client-specific progress in this context.

A. Determine apical heart rate and rhythm. B. Observe color and amount of urine. C. Assess strength of deep tendon reflexes. D. Compare muscle strength bilaterally.

Correct Answer is A

Explanation

Choice A reason: Hypokalemia (2.5 mEq/L) risks cardiac dysrhythmias, as potassium is critical for cardiac conduction. Assessing apical heart rate and rhythm is most important to detect life-threatening arrhythmias like ventricular tachycardia. This guides urgent potassium replacement, aligning with emergency care and electrolyte imbalance management protocols.

Choice B reason: Observing urine color and amount assesses hydration but is less urgent than cardiac monitoring in hypokalemia. Low potassium primarily affects cardiac function, not urine output. Heart rhythm assessment takes precedence to prevent arrhythmias, per prioritization in electrolyte imbalance and critical care nursing standards.

Choice C reason: Assessing deep tendon reflexes is relevant for hyperkalemia, not hypokalemia, which causes muscle weakness, not reflex changes. Cardiac effects of low potassium are more critical, requiring heart rhythm monitoring first. This is less prioritized, per electrolyte imbalance and neurological assessment guidelines in acute care.

Choice D reason: Comparing muscle strength bilaterally detects hypokalemia-related weakness but is secondary to cardiac risks. Arrhythmias from low potassium are life-threatening, making heart rhythm assessment the priority. Muscle strength can be evaluated later, per prioritization of cardiac stability in electrolyte imbalance management and critical care protocols.

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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

When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. Which action should the nurse take next?

Correct Answer is C

Explanation

When assessing a client with a serum potassium level of 2.5 mEq/L (2.5 mmol/L), which intervention is most important for the nurse to implement? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is A

Explanation

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?

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