A nurse is caring for a client who has pneumonia. Assessment findings include T 100.4 deg F, RR 30, BP 130/76, HR 100, and SpO2 91% on room air. Which of the following is the PRIORITY intervention?

Perform a sputum culture

Instruct the patient to obtain yearly influenza vaccination

Administer oxygen therapy

Administer antibiotics

Answer and Explanation

The Correct Answer is C

A.   While obtaining a sputum culture is important for identifying the causative organism and guiding antibiotic therapy, it is not an immediate priority. Delaying this test briefly for critical interventions (like oxygen administration) is acceptable, as stabilizing the patient's oxygen levels is more urgent.
B.   Educating the patient about vaccination is important for long-term health and prevention of future respiratory infections. However, it does not address the current situation and does not provide immediate benefit for the acute episode of pneumonia.
C.   The patient has a SpO2 of 91%, which indicates hypoxemia (low oxygen levels in the blood). In pneumonia, adequate oxygenation is crucial to prevent further respiratory distress and potential complications. Administering oxygen therapy will help improve the oxygen saturation and support the patient’s respiratory function, making this the highest priority intervention.
D.   While antibiotics are essential for treating bacterial pneumonia, they may take time to exert their effects. In this acute scenario, the immediate need is to ensure the patient is adequately oxygenated. After oxygen is administered, antibiotics can be given promptly.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["C","D"]

Explanation

A. Premature Ventricular Contractions (PVC's) (A) are related to cardiac activity and not directly indicative of respiratory function.
B. A respiratory rate of 14 breaths per minute is within the normal range for adults (12-20 breaths per minute). Therefore, this finding does not indicate a decline in respiratory status.
C. Circumoral cyanosis, which refers to a bluish discoloration around the mouth, indicates hypoxia and is a sign of deteriorating respiratory status. It suggests that the body is not getting enough oxygen, which is critical to monitor in an asthma attack.
D. Retractions, especially of the sternal muscles, are a sign of increased work of breathing and can indicate severe respiratory distress. This finding suggests that the patient is struggling to breathe effectively, indicating a decline in respiratory status.
E. An SpO2 of 95% is generally considered acceptable, especially in patients with asthma, as normal oxygen saturation levels typically range from 95% to 100%. While it is at the lower end of normal, it does not indicate an immediate decline in respiratory status.

A. Show expected changes in white blood cell counts. B. Skin tests for tuberculosis may be falsely negative. C. Should receive influenza, pneumococcal, and shingles vaccinations. D. Higher risk for respiratory tract and genitourinary infections. E. Booster vaccinations are not likely needed as one ages. F. May not have a fever with severe infection.

Correct Answer is ["B","C","D","F"]

Explanation

A. Aging can lead to changes in immune function, including alterations in white blood cell counts. While absolute counts may not be drastically lower, the immune response may be less effective. This is important information as it helps the patient understand their altered immune status and potential infection risks.
B. Older adults may have a diminished immune response, which can lead to false-negative results in tuberculosis skin tests (e.g., PPD test). This is crucial information, as it can affect diagnosis and treatment decisions, highlighting the need for alternative screening methods.
C. Vaccinations are critical for older adults to help prevent infections. Influenza, pneumococcal, and shingles vaccines can significantly reduce the risk of these infections, which are more severe in the elderly. This is an essential component of their health maintenance.
D. Older adults are at increased risk for respiratory tract infections (like pneumonia) and genitourinary infections (like urinary tract infections) due to factors such as comorbidities and changes in immune function. Educating clients about these risks helps them recognize symptoms and seek timely care.
E. Older adults often require booster vaccinations to maintain immunity, as their immune response may diminish over time. This misinformation could lead to increased susceptibility to vaccine-preventable diseases.
F. It is common for elderly individuals to present with atypical signs of infection, including the absence of fever even in severe cases. This is important for both the patient and caregivers to understand, as it may lead to delayed recognition and treatment of infections.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has pneumonia. Assessment findings include T 100.4 deg F, RR 30, BP 130/76, HR 100, and SpO2 91% on room air. Which of the following is the PRIORITY intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the Emergency Department (ED) is caring for a client who is having acute asthma attack. Which of the following assessments indicates that the respiratory status is declining?(Select all that apply)

Correct Answer is ["C","D"]

Explanation

The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply.)

Correct Answer is ["B","C","D","F"]

Explanation

All of the following are common causes of Iron deficiency anemia, EXCEPT?

The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply.)

Your cancer patient has bone marrow suppression from their chemotherapy treatments, and is scheduled to receive Epoetin Alfa shots 3 times per week. Which of the following lab values would cause you to hold the administration of the medication for safety concerns?

A patient with iron deficiency anemia who is taking oral iron supplements is evaluated by the nurse in the outpatient clinic. Which finding by the nurse is of MOST concern?

Which of the following is are appropriate nursing interventions to ensure the safety of a patient who is receiving Total Parenteral Nutrition (TPN)? (Select all that apply)

A nurse is teaching a client who has SLE (Lupus) about self-care. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is providing teaching for a client who has stage 3 HIV disease (AIDS). Which of the following statements by the client should indicate to the nurse an understanding of the teaching?