A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia.

Exhibits

Which of the following actions should the nurse take first?

Administer oxygen via nasal cannula.

Obtain a sputum culture.

Administer an antipyretic medication.

Encourage the client to increase fluid intake.

Answer and Explanation

The Correct Answer is A

Choice A Rationale: Administeíing oxygen via nasal cannula is the fiíst píioíity in this scenaíio. ľhe client’s oxygen satuíation is 88% on íoom aií, which indicates hypoxemia. Píoviding supplemental oxygen will help impíove the client’s oxygenation and alleviate symptoms of shoítness of bíeath. Ensuíing adequate oxygenation is cíucial to píevent fuítheí íespiíatoíy distíess and potential complications.
Choice B Rationale: Obtaining a sputum cultuíe is impoítant to identify the causative oíganism of the client’s íespiíatoíy infection and guide appíopíiate antibiotic theíapy. Howeveí, this action is not the immediate píioíity. Addíessing the client’s hypoxemia by administeíing oxygen takes píecedence to stabilize the client’s condition.
Choice C Rationale: Administeíing an antipyíetic medication can help íeduce the client’s feveí and impíove comfoít. Howeveí, this is not the immediate píioíity. ľhe client’s hypoxemia and íespiíatoíy distíess need to be addíessed fiíst by administeíing oxygen.
Choice D Rationale: Encouíaging the client to incíease fluid intake is impoítant foí maintaining hydíation and helping to thin íespiíatoíy secíetions. Howeveí, this action is not the immediate píioíity. ľhe client’s hypoxemia and íespiíatoíy distíess need to be addíessed fiíst by administeíing oxygen.

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Correct Answer is A

Explanation

Choice A rationale
Asking specifically about alcohol, marijuana, cocaine, heroin, and amounts provides a clear and direct approach to obtaining accurate information about the client’s substance use. This method helps in identifying potential health risks and planning appropriate care.
Choice B rationale
Using the term “illegal” or “illicit” to describe street drugs may cause the client to feel judged or defensive, which can hinder open communication. It is better to ask about specific substances directly.
Choice C rationale
Allowing the client to decline answering social questions may result in incomplete health history, which can affect the quality of care provided. It is important to encourage clients to share relevant information while ensuring confidentiality.
Choice D rationale
Obtaining a drug urine screen to verify the legitimacy of the client’s stated history is not an appropriate initial assessment technique. Trust and rapport should be established first through direct questioning.

A. Appropriate weight for height, good general health. B. Extreme obesity, at risk for multiple co-morbidities. C. Undernutrition, at risk for malnutrition. D. Obese, serious threat to well-being.

Correct Answer is D

Explanation

Choice A rationale
A BMI of 32 kg/m² is not considered an appropriate weight for height. According to the American Heart Association, a BMI between 18.5 and 24.9 kg/m² is considered normal weight. A BMI of 32 kg/m² falls into the obese category, which indicates excess body fat and potential health risks.
Choice B rationale
While a BMI of 32 kg/m² is classified as obese, it is not categorized as extreme obesity. Extreme obesity is typically defined as a BMI of 40 kg/m² or higher. Therefore, this choice is incorrect.
Choice C rationale
A BMI of 32 kg/m² does not indicate undernutrition or malnutrition. Undernutrition is associated with a BMI of less than 18.5 kg/m². This choice is incorrect as the BMI in question indicates obesity, not undernutrition.
Choice D rationale
A BMI of 32 kg/m² is classified as obese. Obesity is a serious threat to well-being as it increases the risk of various health conditions, including heart disease, diabetes, hypertension, and certain cancers. Therefore, this choice is correct.

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A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia. Exhibits Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client’s use of illegal drugs and alcohol?

Correct Answer is A

Explanation

The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m². Based on this BMI, what should the nurse deduce about this client’s general health?

Correct Answer is D

Explanation

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A nurse is caring for a 65-year-old male client in the clinic who presents with shortness of breath and a productive cough. The client has a history of smoking and was recently treated with antibiotics for pneumonia.

Exhibits

Which of the following actions should the nurse take first?