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","E"]
Explanation
An oral airway can help maintain an open airway during a seizure.
Supplemental oxygen supplies can be used to provide oxygen if the client’s breathing is compromised.
Oral suction equipment can be used to clear secretions from the client’s mouth and prevent aspiration.
Limb restraints: Restraints should not be used during a seizure as they can cause injury.
Blood glucose monitor: While it is important to monitor blood glucose levels in clients with seizures, it is not a priority during a seizure.
Correct Answer is A
Explanation
This is because chest percussion uses clapping of the chest using a cupped hand to vibrate the airways of the lungs and move and break apart the mucus inside the lungs.
Covering the area of percussion with a towel can help to reduce discomfort during the procedure.
Choice B is wrong because postural drainage should not be scheduled after meals.
It is best to schedule postural drainage before meals or at least 1-2 hours after meals to prevent discomfort or vomiting.
Choice Cis wrong because, during vibration, the client should inhale deeply and exhale slowly.
Choice Dis wrong because percussion should not be performed over the lower back.
It should be performed over the chest and back, avoiding areas such as the spine and breastbone.
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