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 B

Explanation

A. It is accurate that vaccination is most effective before symptoms appear, but this statement does not address the client's immediate need for treatment.
B. Oseltamivir (Tamiflu) is an antiviral medication that can be prescribed for influenza symptoms if taken within the first 48 hours of symptom onset, making it appropriate to refer the client for a prescription.
C. While over-the-counter medications may help alleviate some symptoms, they do not treat the underlying viral infection, and antiviral medications can be more effective.
D. This statement is true but does not directly answer the client's question about the treatment of influenza with oseltamivir.

A. Determine the client's last dose of corticosteroids. B. Determine neurological baseline prior to the fall. C. Administer a PRN IV antiemetic as prescribed. D. Complete head-to-toe neurological assessment.

Correct Answer is D

Explanation

A. Determine the client's last dose of corticosteroids: This may be helpful later in understanding the client's MS management, but it is not the immediate priority in an acute neurological situation.
B. Determine neurological baseline prior to the fall: While important for comparison, establishing the client’s current status through assessment takes priority.
C. Administer a PRN IV antiemetic as prescribed: Vomiting may be a sign of increased intracranial pressure (ICP); treating the symptom without assessing for underlying neurological compromise could delay recognition of a critical condition.
D. Complete head-to-toe neurological assessment: This is the priority. The client’s confusion and projectile vomiting may indicate a traumatic brain injury with increased ICP. Immediate neurological assessment is necessary to identify life-threatening changes and guide urgent interventions.

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Naxlex Comprehensive Predictor Exams

A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?

Correct Answer is B

Explanation

A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

Exhibits Which prescriptions would the nurse question? Select all that apply.

The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

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?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

Exhibits Which of the following does the nurse anticipate the healthcare provider to prescribe during morning rounds? Select 4 findings.

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client's serum laboratory values is most important for the nurse to review?

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?