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 A

Explanation

A. A corneal abrasion is a condition that may be exacerbated by the use of ketorolac due to its potential to delay healing and increase bleeding risks. Therefore, it is essential to ensure that a patient does not have a corneal abrasion before administering ophthalmic ketorolac.

B. Radiation exposure is not directly relevant to the administration of ophthalmic ketorolac.

C. The presence of a foreign body is not directly related to ketorolac use

D. The presence of a chemical burn is not related with ketorolac use in a client.

A. Uncontrollable shaking. B. Throat irritation. C. Increased anxiety. D. Irregular rapid heart beat.

Correct Answer is D

Explanation

D. One of the potential side effects of albuterol is tachycardia (irregular rapid heart beat) due to its stimulatory effects on beta-adrenergic receptors in the heart.

A. While tremors can be distressing for the client, they are generally benign and do not typically require immediate intervention by the nurse.

B. While uncomfortable, throat irritation is generally mild and self-limiting and does not typically require immediate intervention by the nurse.

C. Increased anxiety alone does not typically warrant immediate intervention by the nurse unless it is severe or accompanied by other concerning symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for ophthalmic ketorolac, Prior to administering the medication, the nurse should review the medical record for which condition?

Correct Answer is A

Explanation

A client with emphysema reports difficulty breathing and exhibits audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants Immediate intervention by the nurse?

Correct Answer is D

Explanation

Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

Patient Data Exhibits What order(s) would the nurse question? (Select all that apply.)

An older adult client is hospitalized with a fractured femur. During a routine nursing assessment, the client repeatedly asks the nurse to "speak up" so that the client can hear the questions. Which action is best for the nurse to take?

The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 mL of DW to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many glt/minute? (Enler numeric value only. If rounding is required, round to the nearest whole number.)

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?