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 A

Explanation

A. The Z-track technique helps to prevent medication from leaking into the subcutaneous tissue and minimizes irritation by sealing the medication in the muscle. This is especially important for medications that are known to cause irritation or staining, such as iron supplements or some antipsychotics
B. The length of the needle is not directly related to the use of the Z-track technique. The Z-track method is used to minimize irritation and ensure that the medication is deposited in the muscle rather than leaking into the subcutaneous tissue.
C. The reason for using the Z-track technique is related to preventing irritation and ensuring proper medication delivery, rather than simply following a prescription.
D. The volume of medication is not the primary reason for using the Z-track technique. While the Z-track method can be used for administering larger volumes of medication, the technique's primary purpose is to prevent leakage and reduce tissue irritation.

A. Use background music to promote relaxation. B. Turn on overhead lights while reviewing instructions. C. Stand behind the client to avoid intimidation. D. Provide handouts written at a 12th grade reading level.

Correct Answer is D

Explanation

A. While music can be relaxing, it may also be distracting and make it difficult for the client to focus on the instructions.
B. Bright overhead lights can be uncomfortable and may even cause strain on the eyes. It's generally better to use soft, natural lighting when reviewing instructions.
C. Standing behind the client can make them feel intimidated or uncomfortable, especially if they are already feeling anxious or overwhelmed. It's better to stand in front of the client and maintain eye contact to show that you are engaged and attentive.
D. Older adults may have difficulty understanding written information that is too complex. Providing handouts written at a 12th grade reading level ensures that the client can easily comprehend the instructions and follow them at home.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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