An adult client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?

Administer a prescribed antipyretic.

Offer a prescribed PRN analgesic.

Suction to clear secretions from airway.

Obtain arterial blood gases.

Answer and Explanation

The Correct Answer is C

C. The client's weak cough effort and use of accessory muscles to breathe suggest the presence of retained respiratory secretions, which can impair breathing and lead to further respiratory compromise. Suctioning to clear secretions from the airway can help improve air exchange and alleviate respiratory distress.

A. The client's primary issue appears to be respiratory distress rather than fever.

B. Offering pain relief is important for overall comfort but it is not be the most immediate intervention needed to address the client's respiratory distress.

D. Arterial blood gases may provide valuable information but they may not be the most immediate intervention needed to address the client's respiratory distress.

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Correct Answer is D

Explanation

D. The priority nursing intervention should be to assess and stabilize the patient's immediate medical needs. The confusion and vomiting could be indicative of increased intracranial pressure or another acute condition requiring immediate attention. Therefore, the most appropriate first action would be to complete a head-to-toe neurological assessment.

A. Determining the last dose of corticosteroids may not address the immediate concerns of confusion and projectile vomiting.

B. Administering an antiemetic is not the priority action as the vomiting is likely due to head trauma with subsequent raised ICP.

C. Understanding the baseline neurological status is essential for subsequent assessment and management but it may not address the immediate concerns of confusion and vomiting.

A. Provide step by step verbal directions. B. Orient the client to the color coding system used for locating hospital services. C. Use the hospital map to show the client where the cafeteria is located. D. Escort the client to the cafeteria.

Correct Answer is D

Explanation

D. For individuals with Huntington's disease, who may experience motor impairments and difficulties with coordination and balance, having someone escort them to the cafeteria could be the most practical and supportive approach.

A. Verbal directions may be a component of assistance but they may not be the most effective approach on their own.

B. Individuals with Huntington's disease may still have difficulties with executive function and orientation, which could limit their ability to effectively use a color coding system independently.

C. Providing a visual representation of the hospital layout using a map could be a helpful approach for a client with Huntington's disease. However, the cognitive and motor impairment present may hinder access even in the presence of a map.

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Naxlex Comprehensive Predictor Exams

An adult client with multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

Correct Answer is D

Explanation

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea, tachypnea with coughing. After positioning the client upright, which action should the nurse take next?

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