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 voiding after intercourse can help reduce the risk of urinary tract infections (UTIs), it is not directly related to preventing vaginal tears. This practice is more relevant for preventing infections rather than addressing the issue of tissue trauma or dryness that may lead to tearing.
B. Regular well-woman exams are important for overall gynecological health and early detection of potential issues, but they do not directly address the immediate concern of preventing vaginal tears during intercourse.
C. Vaginal dryness is a common issue in older women, often due to decreased estrogen levels. Dryness can make vaginal tissues more susceptible to tearing during intercourse. Using vaginal lubricants can help reduce friction and prevent tears, making this the most relevant and practical advice for the client in this situation.
D. While certain positions may be more comfortable and could potentially reduce the risk of tearing, this advice is secondary to addressing the fundamental issue of vaginal dryness. Focusing on lubrication provides a more direct and effective approach to preventing tears.

A. Gather a history from adult child about circumstances of previous falls. B. Inform the adult child that fall prevention is a priority for older adults. C. Ask the adult child to remain with the client during the examination. D. Encourage the adult child to report the incident to other siblings.

Correct Answer is A

Explanation

A. Understanding the circumstances of previous falls can help identify any risk factors that may have contributed to the current fall. This information can be used to develop a plan to prevent future falls. By gathering information about previous falls, the nurse can develop a more comprehensive plan to address the client's specific needs and reduce the risk of future falls.
B. While it's important to educate the adult child about fall prevention, gathering information about previous falls is a more immediate priority.
C. Asking the adult child to remain with the client is appropriate, but it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.
D. While informing other family members may be important, it's not the most immediate action needed. Gathering information about previous falls is more important at this stage.

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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

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