A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?

Dry, occasional cough.

Temperature or Febrile 103 degrees F (39.4 degrees C)

Clear, watery drainage from the nose

Scratchy throat

Answer and Explanation

The Correct Answer is B

A.   Dry, occasional cough: A dry, occasional cough is a common symptom of upper respiratory infections and may not necessarily indicate a complication.
B.   Temperature or Febrile 103 degrees F (39.4 degrees C): A high fever (over 100.4 degrees F or 38 degrees C) is a concerning symptom that may indicate the development of a complication such as pneumonia or a secondary bacterial infection.
C.   Clear, watery drainage from the nose: Clear, watery drainage from the nose is typically associated with viral upper respiratory infections and may not necessarily indicate a complication.
D.   Scratchy throat: A scratchy throat is a common symptom of upper respiratory infections and may not necessarily indicate a complication.

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Correct Answer is A

Explanation

A. Obtain a sputum culture: Obtaining a sputum culture helps identify the causative organism of pneumonia, which guides appropriate antibiotic therapy.
B. Cough and deep breathe every 6 hours: While coughing and deep breathing exercises are important for preventing complications such as atelectasis, they are not specific to pneumonia treatment and may not be appropriate for all patients with pneumonia.
C. Encourage fluid intake of 1500 mL/day: Adequate fluid intake is generally recommended for overall health but is not a specific intervention for pneumonia treatment.
D. Position the client prone: Positioning the client prone is not a standard intervention for pneumonia treatment. Depending on the severity and type of pneumonia, the client's positioning may vary, but prone positioning is not routinely recommended.

A. A client who has swelling, tenderness, and purulent drainage around the wound B. A client who has urticaria and itching around the wound C. A client who has serosanguineous drainage from the wound D. A client who has brown crusting over the wound

Correct Answer is A

Explanation

A. Swelling, tenderness, and purulent drainage around the wound are classic signs of a wound infection. Swelling and tenderness indicate inflammation, while purulent drainage (pus) suggests the presence of infection.
B. Urticaria and itching around the wound are more indicative of an allergic reaction or hypersensitivity rather than a wound infection.
C. Serosanguineous drainage (clear to blood-tinged fluid) is a normal finding in the early stages of wound healing and does not necessarily indicate infection.
D. Brown crusting over the wound may indicate the formation of an eschar, which can occur in wounds undergoing healing, particularly in wounds with necrotic tissue. It is not necessarily indicative of infection unless accompanied by other signs such as erythema, warmth, or purulent drainage.

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A patient has been recently diagnosed with an upper respiratory infection. His brother arrives and would like to visit. The patient says he is not feeling strong enough to have visitors. Which symptom would indicate to the nurse that the client is developing a complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client showing signs of pneumonia. Which of the following nursing actions should be included?

Correct Answer is A

Explanation

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

Correct Answer is A

Explanation

The nurse has contributed to a staff education program about the principles for the first tier of standard precautions. Which statement by a nursing student indicates a correct understanding of the teaching?

The nurse is taking care of a patient diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA). The nurse knows that this disease is difficult to treat and has a high mortality rate. Which medication would the nurse expect to be ordered to treat this infection?

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A nurse is caring for a client who has a Clostridium difficile infection. Which of the following cleansing agents should the nurse use for hand hygiene?

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