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 C

Explanation

A. While some clients may need to manage fluid intake based on their symptoms, it is not the primary dietary restriction for Crohn's disease.
B. Clients with Crohn's disease often need to focus on nutrient-rich foods; limiting calcium and iron is not generally advised unless specific deficiencies are present.
C. An elimination diet can help identify trigger foods that exacerbate symptoms, making this response appropriate and beneficial for managing Crohn's disease.
D. Avoiding gluten is specifically related to celiac disease rather than Crohn's disease, as not all individuals with Crohn's need to eliminate gluten unless they have an associated gluten sensitivity.

A. Acute pancreatitis. B. Biliary duct obstruction. C. Surgical site infection. D. Hepatorenal failure.

Correct Answer is A

Explanation

A. The symptoms of persistent upper abdominal pain radiating to the back, elevated serum amylase and lipase levels, vomiting, and fever suggest acute pancreatitis, which can occur after cholecystectomy due to potential injury to the pancreas or bile duct obstruction.
B. While biliary duct obstruction can occur postoperatively, the significantly elevated amylase and lipase levels, along with the described symptoms, more strongly indicate pancreatitis.
C. Surgical site infection typically presents with localized symptoms rather than systemic symptoms like elevated amylase and lipase.
D. Hepatorenal failure is unlikely to present with these specific gastrointestinal symptoms and enzyme elevations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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

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

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 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?

Exhibits The client undergoes several days of antibiotic and respiratory treatment for his pneumonia. Mark whether the assessment findings indicate that the treatment was effective or ineffective. Each row must have one option selected.

A client who has had a laryngectomy and tracheostomy frequently expectorates copious amounts of purulent secretions. When changing the ties of the tracheostomy tube, which action is most important for the nurse to take?