A nurse enters a client's room to administer medication and finds the client lying in bed disoriented with labored and fast respirations. Which of the following actions should the nurse take first?

Prepare the client for endotracheal suctioning.

Elevate the head of the bed.

Request a chest x-ray.

Obtain a sputum culture.

Answer and Explanation

The Correct Answer is B

A. Prepare the client for endotracheal suctioning.

Endotracheal suctioning is a procedure used to clear secretions from the airway, which may be necessary in cases of respiratory distress. However, it is not the first action to take in this scenario. Before proceeding with suctioning, the nurse should first assess the client's respiratory status and implement interventions to improve ventilation and oxygenation.

B. Elevate the head of the bed.

This is the correct action to take first. Elevating the head of the bed helps improve the client's respiratory mechanics by allowing better lung expansion and reducing the work of breathing. It also helps alleviate symptoms of respiratory distress. This intervention should be implemented immediately to optimize the client's breathing.

C. Request a chest x-ray.

While a chest x-ray may provide valuable information about the client's respiratory status, it is not the first action to take in this acute situation. Chest x-rays require time to be performed and interpreted, which may delay necessary interventions to address the client's immediate respiratory distress.

D. Obtain a sputum culture.

Obtaining a sputum culture may be indicated to identify the underlying cause of respiratory distress, such as infection. However, it is not the first action to take when the client is experiencing acute respiratory distress. The priority is to implement interventions to improve ventilation and oxygenation to stabilize the client's condition.

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Correct Answer is A

Explanation

A. Fatigue

When collecting data from a client with pulmonary tuberculosis (TB), the nurse should expect to observe fatigue as one of the common manifestations. TB is a bacterial infection caused by Mycobacterium tuberculosis, primarily affecting the lungs. Fatigue is a typical symptom experienced by individuals with TB, often resulting from the body's immune response to the infection, as well as the systemic effects of inflammation and tissue damage caused by the bacteria.

B. High fever in the early morning

While fever is a symptom of tuberculosis, it may not necessarily occur specifically in the early morning. Fever associated with TB can occur at any time of the day and may persist for weeks to months. The pattern of fever can vary among individuals and may not consistently occur in the early morning.

C. Edema

Edema, or swelling due to fluid accumulation in tissues, is not typically associated with pulmonary tuberculosis. Edema is more commonly observed in conditions such as heart failure, renal failure, or liver disease, rather than in TB.

D. Increased appetite

Increased appetite is not a typical finding in pulmonary tuberculosis. In fact, individuals with active TB infection often experience appetite loss and unintended weight loss due to factors such as decreased food intake, metabolic changes, and systemic inflammation associated with the infection.

A. 24 year old woman with allergic rhinitis B. 18 year old man with cold symptoms C. 64 year old woman with a history of heart disease D. 70 year old woman with glaucoma E. 56 year old man with prostatic hypertrophy

Correct Answer is ["B"]

Explanation

A. 24-year-old woman with allergic rhinitis:

Likely safe to take an alpha-adrenergic decongestant as allergic rhinitis is a common indication for decongestant use in young, healthy individuals.

B. 18-year-old man with cold symptoms:

Likely safe to take an alpha-adrenergic decongestant as it's a common indication for decongestant use in young, healthy individuals.

C. 64-year-old woman with a history of heart disease:

Should avoid alpha-adrenergic decongestants due to the risk of increasing blood pressure and potentially worsening heart conditions.

D. 70-year-old woman with glaucoma:

Should avoid alpha-adrenergic decongestants due to the risk of exacerbating glaucoma by causing pupil dilation and increasing intraocular pressure.

E. 56-year-old man with prostatic hypertrophy:

Should avoid alpha-adrenergic decongestants due to the risk of worsening urinary symptoms caused by prostatic hypertrophy, such as urinary retention.

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A nurse enters a client's room to administer medication and finds the client lying in bed disoriented with labored and fast respirations. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

Which patient(s) would be able to take an alpha-adrenergic decongestant safely? (SELECT ALL THAT APPLY)

Correct Answer is ["B"]

Explanation

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