A client is admitted with possible pneumonia. When entering the room, the nurse observes the client's face as seen in the picture. Which prescription should the nurse implement first?

Measure body temperature.

Administer PRN oxygen.

Send for chest x-ray.

Obtain sputum for culture.

Answer and Explanation

The Correct Answer is B

A.   Measuring body temperature is important in assessing the client’s overall condition and identifying a fever, which is common in pneumonia. However, while it provides useful information about the client's status, it is not the most urgent action compared to interventions that could immediately impact the client’s respiratory function or confirm the diagnosis.
B.   Administering PRN (as needed) oxygen is crucial if the client shows signs of hypoxia or difficulty breathing. If the client's face appears cyanotic or if they are experiencing respiratory distress, this action should be prioritized to ensure adequate oxygenation.
C.   A chest x-ray is essential for diagnosing pneumonia and assessing the extent of lung involvement. However, while it is critical for diagnosis, addressing immediate respiratory needs and symptoms takes precedence.
D.   Obtaining sputum for culture is important for identifying the causative organism and guiding antibiotic therapy. However, this action is less urgent than ensuring the client’s immediate respiratory needs are met and confirming the diagnosis through imaging.

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Correct Answer is C

Explanation

A. While practicing strength-building exercises for the arms, such as isometric exercises for the biceps and triceps, is beneficial for overall crutch use, it does not directly indicate proper crutch walking technique.
B. This choice is not correct for a three-point gait, especially in the case of a broken foot. In a three-point gait, the client should avoid bearing weight on the affected leg, as this gait is used to promote healing of a non-weight-bearing limb.
C. This behavior indicates a correct understanding of crutch walking. In the three-point gait, the client should bear weight on the crutches' handles and not on the armpits, which helps prevent nerve damage and provides better stability.
D. While it is important for safety to ensure that the rubber tips of the crutches are intact and not worn out, this behavior does not directly demonstrate the client’s understanding of the three-point gait technique.

A. "It is important to dress the right arm first." B. "Dressing must be a frustrating experience for you." C. "We will give you a class on dressing tomorrow." D. "This unit has a policy against staff harassment."

Correct Answer is B

Explanation

A. While providing practical advice is useful, this response does not directly address the client's current emotional state or frustration. The immediate need is to support the client emotionally rather than instructing them on dressing techniques. It may also come off as dismissive of the client’s feelings.
B. This response is the most appropriate because it acknowledges and validates the client’s emotional experience. By recognizing their frustration, the nurse shows empathy and understanding, which can help in building a therapeutic relationship. It also opens up a dialogue for the client to express their feelings and concerns, which can improve their overall comfort and cooperation.
C. While education on dressing techniques is beneficial, this response does not address the client's immediate frustration or emotional needs. It also postpones support and could make the client feel like their current struggles are not being adequately addressed in the moment.
D. This response is defensive and does not address the client’s immediate emotional needs. It may escalate the situation by making the client feel like they are being reprimanded for their behavior. It is important to handle such situations with empathy and support rather than focusing on institutional policies.

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A client is admitted with possible pneumonia. When entering the room, the nurse observes the client's face as seen in the picture. Which prescription should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

The nurse is demonstrating three-point gait crutch walking to an older adult man who broke his foot while playing soccer with his grandchildren. Which behavior indicates that the client understands proper crutch walking?

Correct Answer is C

Explanation

A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?

Correct Answer is B

Explanation

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