A nurse is caring for a client who has pneumonia. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

Initiate humidification therapy.

Encourage the client to cough and deep breathe.

Increase the client's oral fluid intake.

Raise the head of the bed.

Answer and Explanation

The Correct Answer is D

Choice A reason: Initiating humidification therapy can be beneficial for a client with pneumonia. Humidified air can help loosen respiratory secretions, making them easier to expectorate. However, while this intervention is helpful, it is not typically the first action a nurse should take. The priority is to address the client's immediate need for adequate oxygenation and ventilation.

Choice B reason: Encouraging the client to cough and perform deep breathing exercises is an essential part of care for patients with pneumonia. These actions help to clear mucus from the lungs and improve ventilation. Deep breathing helps to fully expand the alveoli, which can be compromised in pneumonia, and coughing helps to expel secretions that may be blocking the airways. However, this is not the most immediate action when the oxygen saturation is borderline normal.

Choice C reason: Increasing the client's oral fluid intake is important in the management of pneumonia. Adequate hydration thins respiratory secretions, making them easier to clear. It also supports overall bodily functions, which can be taxed during illness. Nonetheless, this intervention is not the most critical initial step in managing a client's immediate respiratory needs.

Choice D reason: Raising the head of the bed is the correct and immediate action to take for a client with pneumonia and an oxygen saturation of 88%. This position helps to improve chest expansion, promotes better lung aeration, and facilitates easier breathing. It also reduces the risk of aspiration, which is particularly important in clients with pneumonia. Elevating the head of the bed is a simple yet effective way to enhance oxygenation and should be the first step taken.

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 ["B","C","D"]

Explanation

Choice A reason: Placing a client with active pulmonary TB in a room with positive airflow is not recommended, as positive airflow would push potentially contaminated air into general circulation, risking the spread of TB. Instead, a room with negative airflow is appropriate to contain and remove contaminated air.

Choice B reason: Determining whether the client lives alone or with others is important for public health and contact tracing purposes. If the client lives with others, those individuals may need to be tested and monitored for TB as well.

Choice C reason: Using an alcohol-based hand cleaner is a standard practice unless hands are visibly soiled. If hands are visibly soiled, handwashing with soap and water is necessary.

Choice D reason: Reminding the client to cover their mouth with a tissue when coughing is a key measure to prevent the spread of TB, which is transmitted through airborne particles from coughs or sneezes.

Choice E reason: Antifungal medications are not used to treat TB, which is caused by a bacterium, not a fungus. The client should be instructed about taking anti-tuberculosis medications, not antifungals.

A. Wrap the dressing in a clear plastic bag and discard it in the bedside trash receptacle. B. Discard the dressing in the bedside trash receptacle. C. Place the dressing in a biohazardous waste container. D. Double bag the dressing, label it "biohazard," and send it for decontamination.

Correct Answer is C

Explanation

Choice A reason: Wrapping the dressing in a clear plastic bag and discarding it in the bedside trash receptacle is not an appropriate method for disposing of soiled dressings. This approach does not comply with standard infection control protocols, as it could potentially expose healthcare workers and others to biohazardous materials.

Choice B reason: Simply discarding the dressing in the bedside trash receptacle is also inappropriate and unsafe. This method does not contain the biohazardous material properly and could lead to contamination and spread of infectious agents.

Choice C reason: Placing the dressing in a biohazardous waste container is the correct method for disposing of dressings saturated with blood and purulent drainage. According to infection control guidelines, materials that are soaked with potentially infectious agents should be disposed of in designated biohazardous waste containers. These containers are typically red or yellow and are labeled to indicate that they contain materials that require special handling.

Choice D reason: Double bagging the dressing, labeling it "biohazard," and sending it for decontamination is an unnecessary step for routine disposal of soiled dressings. While double bagging may be used in situations where there is a significant spill or leak risk, it is not typically required for standard disposal of wound dressings.

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. The client's oxygen saturation is 88%. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who was placed on isolation precautions for active pulmonary tuberculosis (TB). Which of the following actions should the nurse plan to take? (Select all that apply.)

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

Explanation

A nurse is removing a wound dressing that is saturated with blood and purulent drainage. Which of the following methods should the nurse use when disposing of the soiled dressing?

Correct Answer is C

Explanation

A client complains of an inability to sleep through the night since admission three days ago. Which of the following factors is most likely to negatively affect the patient's sleep patterns?

A nurse is collecting data about a client's circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?

A nurse inserts an indwelling urinary catheter for a client who is preoperative. Three days later, the client develops a urinary tract infection. The nurse should identify that the client has which of the following types of infections?

A nurse is caring for a group of clients. For which of the following tasks should the nurse plan to wear protective eye equipment?

A nurse is applying a cold compress for pain and minor swelling for a client who has a sutured laceration on the forearm. Which of the following data-collection activities should the nurse use to determine whether the treatment is effective?

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?