A client receiving chemotherapy develops a cough that is productive of yellow-tinged sputum. After determining that the client is afebrile, which is the priority action for the practical nurse (PN) to take?

Plan to re-assess the client's temperature in two hours.

Notify the charge nurse of the assessment findings.

Measure and record the client's intake and output.

Provide oral hygiene on a regular, frequent schedule.

Answer and Explanation

The Correct Answer is B

A. Re-assessing the client’s temperature is important but not the priority action since the client is currently afebrile and the cough with yellow sputum could indicate an infection or other condition needing immediate attention.
B. Notifying the charge nurse of the assessment findings is the priority because the yellow-tinged sputum in a client receiving chemotherapy might indicate an infection or complication that requires further investigation and possible intervention.
C. Measuring and recording intake and output is important for overall fluid balance but does not address the immediate concern of a productive cough with potential infection.
D. Providing regular oral hygiene is part of general care but does not address the potential underlying cause of the productive cough and yellow-tinged sputum.

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Correct Answer is A

Explanation

A. Reporting any foot injury or sore that does not readily heal is the most crucial instruction for minimizing long-term complications in diabetes management. Poor circulation and neuropathy in diabetic patients can lead to serious complications from minor foot injuries, so prompt medical evaluation is essential for preventing severe outcomes.
B. Drying feet thoroughly between toes is important for preventing fungal infections, but it is a standard part of foot care rather than a primary measure for preventing long-term complications like ulcers or infections.
C. Ensuring that shoe size fits to minimize rubbing and blisters is important for foot health, but it is not as critical as promptly addressing any injuries or sores that may arise.
D. Monitoring fingerstick glucose daily for tight control is necessary for diabetes management but does not directly address foot care issues. It is important for overall disease management but not specifically for immediate foot care concerns.

A. Administer cholera vaccines. B. Administer prophylactic antibiotics as prescribed. C. Isolate all infectious diarrhea victims. D. Provide fluid and electrolyte replacement.

Correct Answer is D

Explanation

A. Administering cholera vaccines can help prevent further cases but is not the immediate priority for those already infected.
B. Administering prophylactic antibiotics is important but not the highest priority compared to addressing the acute symptoms of cholera.
C. Isolating all infectious diarrhea victims helps prevent the spread of infection but does not address the immediate life-threatening dehydration and electrolyte imbalance.
D. Providing fluid and electrolyte replacement is the highest priority as cholera causes severe dehydration and electrolyte imbalance, which can be fatal if not treated promptly. Immediate rehydration is crucial to save lives.

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A client receiving chemotherapy develops a cough that is productive of yellow-tinged sputum. After determining that the client is afebrile, which is the priority action for the practical nurse (PN) to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which foot care instruction is most important for the practical nurse (PN) to reinforce that minimizes a long-term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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