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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Trouble sleeping may be relevant to the client's overall health but does not directly impact the administration of pyridostigmine.
B. Recent oral intake is crucial to determine if the client can swallow effectively, as pyridostigmine can affect muscle strength, including those involved in swallowing.
C. Unexplained weight loss could indicate other issues but is not immediately pertinent to the administration of this medication.
D. Difficulty with urination may be important for other reasons but does not directly relate to the effects or administration of pyridostigmine.

A. Use salt tablets after strenuous exercise. B. Drink plenty of water whenever thirsty. C. Monitor daily urine output volume. D. Review food labels for sodium content.

Correct Answer is D

Explanation

A. Use salt tablets after strenuous exercise is incorrect. Clients with hypernatremia should avoid excessive sodium intake, including salt tablets, as this can worsen the condition.

B. Drink plenty of water whenever thirsty is incorrect. Thirst is a late sign of dehydration, and clients with hypernatremia should be encouraged to drink water regularly, even before feeling thirsty, to maintain proper hydration and correct sodium imbalances.

C. Monitor daily urine output volume is incorrect. While monitoring fluid balance is important, urine output alone does not directly address sodium intake or management, making reviewing food labels for sodium content a more critical intervention.

D. Review food labels for sodium content is correct. Clients with hypernatremia should limit sodium intake by carefully reading food labels and avoiding processed, canned, and fast foods that are high in sodium.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?

Correct Answer is B

Explanation

Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?

Correct Answer is D

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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?

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?

A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?

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?

Exhibits Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.