A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

Administer the prescribed antipyretic and notify the primary health care provider.

Assess the color and content of the urine specimen for urinalysis.

Note the consistency of respiratory secretions and obtain a specimen for culture.

Compare all prior vital signs and continue to monitor every hour.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.

Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.

Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.

Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.

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Correct Answer is C

Explanation

Choice A reason: Administering an extra dose of albuterol before bedtime is not appropriate. The correct approach is to manage bronchial secretions through other means, such as hydration.

Choice B reason: Using a dehumidifier is not recommended for clients with respiratory issues. A humidifier, not a dehumidifier, helps keep the air moist and can help with secretions.

Choice C reason: Increasing the amount of fluids consumed helps to thin bronchial secretions, making them easier to cough up. Hydration is an effective method to manage secretions and improve respiratory function.

Choice D reason: Increasing daily exercise can be beneficial for overall health but is not the primary method to clear bronchial secretions. Hydration is more directly effective in this situation.

A. "You are right, I cannot really understand. Perhaps you would like to tell me more about what you are feeling." B. "It takes time to get over the loss of a loved one." C. "Why don't you try something to take your mind off your troubles?" D. "I might not share your exact situation, but I do know what people go through when they deal with a loss."

Correct Answer is A

Explanation

Choice A reason: This response acknowledges the client's feelings and validates their experience. It opens the door for the client to express their emotions and share their thoughts. This empathetic approach helps build trust and provides emotional support.

Choice B reason: Telling the client that it takes time to get over the loss of a loved one is a generalized statement that may not provide the support the client needs. It can come across as dismissive and may not encourage further conversation.

Choice C reason: Suggesting that the client try something to take their mind off their troubles can seem dismissive of their grief. It does not address the client's emotional needs or encourage them to talk about their feelings.

Choice D reason: While this response shows some understanding, it does not fully acknowledge the uniqueness of the client's situation. It is important to validate the client's feelings and encourage them to express their emotions.

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A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client prescribed albuterol sulfate by inhalation is unable to cough up secretions. What actions should the nurse teach the client to help clear bronchial secretions effectively?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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