A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?

Encourage the client to cough and deep breathe.

Obtain the client's temperature.

Encourage the client to increase oral fluids.

Provide chest percussion on the client.

Answer and Explanation

The Correct Answer is A

A.   This action helps the client to clear pulmonary secretions and improve ventilation. Coughing and deep breathing exercises are essential for maintaining airway patency and preventing complications such as atelectasis and respiratory distress.
B.   Monitoring the client's temperature is important to assess for fever, which can indicate infection severity or response to treatment. However, in a client actively coughing up secretions, immediate interventions to promote airway clearance take precedence over obtaining temperature.
C.   Adequate hydration can help liquefy pulmonary secretions, making them easier to expectorate. However, this action is secondary to promoting effective coughing and deep breathing to clear secretions already present in the airways.

D.   Chest percussion can help loosen and mobilize secretions in the lungs. However, this intervention requires assessment of the client's respiratory status and may not be appropriate as the first action without first assessing the client's tolerance and condition.

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Correct Answer is A

Explanation

A. After administering the injection, activating the passive needle-safety device involves a mechanism where the safety feature automatically engages. This can include a shield that covers the needle or a mechanism that retracts the needle into the syringe or device. It's crucial to activate this immediately after injection to prevent accidental needlestick injuries.
B. The safety device, once activated, should remain in place and intact on the needle until it is safely disposed of in an appropriate sharps container. Removing the safety device before disposal would expose healthcare workers to potential needlestick injuries.
C. There is no need to make sure the needle retracts into the barrel of the syringe, as the safety device is designed to cover the needle after use.
D. While some devices have a plastic sheath or shield that covers the needle before and after use, the primary action for a passive device is to activate the safety feature that automatically covers or retracts the needle post-injection. Pulling a sheath over the needle manually is more typical for active safety devices or conventional needles with manual sheath covers.

A. At the end of the collection time, urinate and save the urine in a separate container. B. At the beginning of the collection time, urinate and then discard the urine. C. Save each urine collection in a separate container. D. Keep the collection container at room temperature.

Correct Answer is B

Explanation

A. This instruction is incorrect for a 24-hour urine collection. During a 24-hour urine collection, the client should urinate into a designated collection container at the start of the collection period and continue to collect all urine voided over the next 24 hours. The nurse should instruct the client to empty their bladder completely at the end of the 24-hour period into the same container used throughout the collection period. This ensures that all urine produced over the 24 hours is included in the specimen.
B. Discarding the first urine voided at the beginning of the collection period is a common instruction for some types of urine tests, such as for urinary catecholamines or specific timed collections. However, for a 24-hour urine collection, the client should start collecting urine from the very first void and include all subsequent urine produced over the next 24 hours.
C. This instruction is incorrect for a 24-hour urine collection. All urine produced during the 24-hour period should be saved in a single designated collection container. Using separate containers for each void would make it difficult to accurately measure the total volume of urine collected over the specified time frame.

D. Storing the urine collection container at room temperature is generally appropriate for a 24-hour urine collection. This helps maintain the stability of the urine sample and ensures accurate test results. Refrigeration may be required if specified by the healthcare provider for specific tests, but this should be clearly communicated to the client if necessary.

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A nurse is caring for a client who has pneumonia and is coughing up secretions. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is administering an IM injection using a passive needle-safety device. After injection, which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in a provider's office is reinforcing teaching with a client who is to collect a 24-hr urine specimen. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

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