A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?

Obtain arterial blood gases.

Administer a prescribed antipyretic.

Offer a prescribed PRN analgesic.

Suction to clear secretions from airway.

Answer and Explanation

The Correct Answer is D

A. Obtaining arterial blood gases is important for assessing respiratory status but is not the immediate priority.
B. Administering an antipyretic can help reduce fever but does not address the immediate respiratory distress the client is experiencing.
C. Offering an analgesic can improve comfort but is not the priority intervention in this scenario.
D. Suctioning to clear secretions from the airway is the most critical intervention to improve the client’s respiratory status, especially given the weak cough effort and use of accessory muscles, indicating possible airway obstruction or ineffective clearance of secretions.

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Correct Answer is D

Explanation

A. While assessing body temperature is important, it is not the most critical action prior to administering vancomycin.
B. Auscultating bowel sounds can provide information about gastrointestinal function but is not specifically required before administering vancomycin.
C. Measuring oxygen saturation is important in assessing respiratory status but is not related to the administration of vancomycin.
D. Checking serum creatinine is essential because vancomycin can affect renal function, and assessing kidney function is critical before administration to prevent potential toxicity, especially in patients with a history of renal impairment.

A. Belching. B. Yellow sclera. C. Flatulence. D. Amber urine.

Correct Answer is B

Explanation

A. Belching is a common symptom and not an urgent finding in this context.
B. Yellow sclera indicates jaundice, which suggests bile obstruction due to the lodged gallstone in the common bile duct; this is a critical finding that requires immediate attention from the healthcare provider.
C. Flatulence can occur with gastrointestinal distress but does not indicate an immediate complication.
D. Amber urine may indicate dehydration or bilirubin presence, but it is less critical than the yellow sclera in this scenario, which directly indicates liver or bile duct involvement.

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Naxlex Comprehensive Predictor Exams

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

Correct Answer is D

Explanation

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?

Correct Answer is B

Explanation

An adult client is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?

Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

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