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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administering acetaminophen can help reduce fever and discomfort but does not directly address the respiratory distress indicated by tachypnea and stridor.
B. Monitoring the child's oxygen saturation level via pulse oximeter is essential to assess the severity of the respiratory distress. It provides critical information on the child's oxygenation status and helps guide further interventions.
C. Encouraging the child to drink adequate amounts of cool, clear liquids is beneficial for hydration but does not directly address the acute respiratory symptoms of irritability, tachypnea, and stridor.
D. Instructing the mother to play with the child for stimulation and distraction may help alleviate irritability but does not address the underlying respiratory distress, which requires immediate attention.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
- "MRSA is not that big of a deal."
No Understanding: MRSA is a serious infection that can be difficult to treat and can spread. It is important for the client to understand the severity of MRSA. - "I should wash my hands and encourage others who are around me to wash their hands."
Understanding: Hand hygiene is critical in preventing the spread of MRSA. The client is aware of the importance of hand washing for infection control. - "I will no longer be able to transmit MRSA once my surgical site is completely healed."
No Understanding: MRSA can be a persistent infection, and healing of the surgical site does not guarantee that MRSA cannot be transmitted. Proper infection control measures must continue. - "My diet makes a difference in my ability to heal."
Understanding: Nutrition plays a role in the healing process and overall recovery. A balanced diet supports the immune system and aids in wound healing. - "I should only take antibiotics until I feel better."
No Understanding: It is crucial to complete the full course of antibiotics as prescribed to ensure the infection is fully treated and to prevent resistance
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