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
Explanation
“This test will provide information about the function of your liver.” An alanine aminotransferase (ALT) test measures the level of ALT in the blood, which is an enzyme found primarily in the liver.
Elevated levels of ALT can indicate liver damage or disease.
Choice A, “This test will indicate if you are at risk for developing blood clots,” is not correct as an ALT test does not provide information about blood clot risk.
Choice B, “This test will determine if your heart is performing properly,” is not correct as an ALT test does not provide information about heart function.
Choice D, “This test is used to check how your kidneys are working,” is not correct as an ALT test does not provide information about kidney function.
Correct Answer is D
Explanation
The nurse should place the extremity in a dependent position before inserting an IV catheter.
This helps to dilate the veins and make them more visible and easier to access.
Choice A is wrong because the nurse should choose a site that is distal to the most proximal site on the extremity selected.
This helps to preserve more proximal sites for future use if needed.
Choice B is wrong because applying a cool compress before insertion of an IV catheter can cause vasoconstriction and make it more difficult to access the vein.
Instead, a warm compress can be applied to help dilate the veins.
Choice C is wrong because the tourniquet should be placed above, not below, the proposed insertion site to help dilate the vein and make it easier to access.
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