While assessing a client, the practical nurse (PN) observes that the client has a frequent productive cough. Which follow-up assessment should the PN complete first?
Note sputum characteristics.
Monitor white blood cell count.
Measure vital signs.
Assess for dependent edema.
The Correct Answer is C
Rationale:
A. Note sputum characteristics: Documenting the color, consistency, and amount of sputum provides valuable information about potential respiratory infection or inflammation. However, it is not the immediate priority because it does not directly indicate the client’s current physiological stability.
B. Monitor white blood cell count: An elevated WBC count can suggest infection, but laboratory results may not be immediately available. This information supports assessment but does not provide real-time data about the client’s acute status.
C. Measure vital signs: Vital signs offer immediate and objective data on the client’s respiratory and cardiovascular status, including heart rate, respiratory rate, oxygen saturation, and temperature. Given a productive cough, monitoring for fever, tachypnea, or hypoxia is critical to identify acute deterioration and guide prompt intervention.
D. Assess for dependent edema: Checking for edema can indicate fluid overload or cardiac compromise, but in the context of a productive cough, respiratory status takes priority over circulatory findings. Edema assessment is important but not the first action in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Examine the testicles during bathing: Testicular self-examination is best performed during or after a warm bath or shower because heat causes relaxation of the scrotal skin, allowing the testes to hang lower and making abnormalities easier to detect. The client should gently roll each testicle between the fingers and thumb to identify any masses, nodules, or changes in consistency.
B. Manipulate the testicles upon rising: Performing the examination upon waking is less effective because the scrotum is typically more contracted in cooler conditions, making palpation more difficult. This can limit the ability to accurately detect subtle changes in testicular size or texture.
C. Inspect the testicles using a mirror: While visual inspection can help identify swelling or asymmetry, it is not the primary method for detecting testicular abnormalities. Most significant findings, such as small masses or nodules, are identified through palpation rather than visual inspection alone.
D. Compare both testicles concurrently: Testicular self-examination should be done one testicle at a time to allow careful palpation of each structure. Although comparing size and consistency is important, attempting to assess both simultaneously reduces accuracy and may lead to missed abnormalities.
Correct Answer is D
Explanation
Rationale:
A. Continue by stroking down the medial side of the sole of the foot: Further stroking is unnecessary if the initial test elicited a normal plantar flexion response. Additional stimulation is not required to confirm a normal response and may cause discomfort to the client.
B. Repeat the same motion with the flat portion of the reflex hammer: Using the flat portion is not indicated for testing the plantar reflex. The pointed end is the standard tool for eliciting this response, and repeating the motion is unnecessary when the initial response is normal.
C. Notify the healthcare provider of the presence of a positive Babinski reflex: A positive Babinski reflex is indicated by dorsiflexion of the big toe and fanning of the other toes, which is abnormal in adults. In this patient, the toes curl downward, indicating a normal plantar flexion response; no abnormal finding exists to report.
D. Record the normal response of plantar flexion in the record: The observed downward curling of the toes represents a normal plantar reflex in an adult. Accurate documentation of this normal neurologic finding is the appropriate next step, ensuring continuity of care and baseline assessment for future comparison.
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