A nurse is caring for a client.
Exhibit 1 Nurses' Notes Day 1: Exhibit 2 Exhibit 3 Client reports fatigue, weight loss, night sweats, and a persistent cough.
Performed a purified protein derivative test on the client and obtained a QuantiFERON-TB Gold blood test as prescribed.
Bilateral breath sounds with crackles and scattered wheezes throughout.
Cough productive for yellow, purulent sputum.
What are the first two actions the nurse should take?
Administer antibiotics and bronchodilators.
Initiate airborne precautions and isolation.
Start the client on cough suppressants and antihistamines.
Obtain sputum culture and chest X-ray.
The Correct Answer is D
The first two actions the nurse should take are to obtain a sputum culture and a chest X-ray.
These tests can help diagnose the cause of the client’s symptoms and guide treatment.
Choice A is wrong because administering antibiotics and bronchodilators should only be done after a diagnosis has been made.
Choice B is wrong because airborne precautions and isolation may not be necessary depending on the cause of the client’s symptoms.
Choice C is wrong because cough suppressants and antihistamines may not be appropriate treatments depending on the cause of the client’s symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
The correct answers are:
- c."I need to have a fire escape plan with my family."
- d."I will use the grab bars when getting in and out of the bathtub."
Rationale for each choice:
Choice c:
Having a fire escape plan is crucial for home safety. It ensures that all family members know what to do in the event of a fire, which can save valuable time and lives. Here's a detailed explanation of why a fire escape plan is essential:
- Early Escape:A plan promotes quick evacuation,as everyone understands the escape routes and procedures.
- Reduced Panic:Knowing what to do in a crisis minimizes panic and confusion,allowing for calmer and more efficient actions.
- Accountability:The plan ensures that no one is left behind,especially children,older adults,or individuals with disabilities.
- Firefighter Assistance:It provides vital information to firefighters,aiding their rescue efforts.
- Regular Practice:Regularly practicing the plan familiarizes everyone with their roles and actions,ensuring smoother execution in a real fire.
Choice d:
Grab bars provide stability and support, reducing the risk of falls in bathrooms. Falls are a major safety hazard, especially for older adults, and can lead to serious injuries. Grab bars offer several benefits, including:
- Entering and Exiting:They facilitate safe entry and exit from the bathtub or shower,especially on slippery surfaces.
- Balance Support:They provide support when standing,reducing the likelihood of losing balance.
- Transfer Assistance:They assist individuals with mobility impairments in safely transferring between the bathtub,shower,or toilet.
- Confidence Boost:They offer a sense of security,allowing individuals to feel more confident and independent in the bathroom.
Rationale for incorrect choices:
Choice a:
Setting a hot water heater to 140 degrees Fahrenheit is unsafe. It can cause scalding burns within seconds, especially for children and older adults. The recommended temperature is 120 degrees Fahrenheit to balance safety and energy efficiency.
Choice b:
Taping over frayed electrical cords is a temporary and hazardous fix. It does not address the underlying issue of damaged wiring, which can lead to electrical shocks, fires, or electrocution. Frayed cords should be replaced immediately with new, undamaged ones.
Correct Answer is C
Explanation
The first two actions the nurse should take are to review the client’s medical history and assess for symptoms.
This can help determine if further testing or treatment is necessary.
Choice A is wrong because the test results are negative, so initiating treatment for TB is not necessary.
Choice B is wrong because repeating the tests may not provide any additional information.
Choice D is wrong because educating the client about TB prevention and management may not be necessary if the client does not have TB.
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