The healthcare provider writes several prescriptions for a client diagnosed with hospital-acquired pneumonia (HAP) that include a combination of broad-spectrum antibiotics. Which intervention should the nurse implement first?

Monitor the client’s metabolic panel results during antibiotic therapy.

Schedule prescribed nebulizer treatments with respiratory therapy.

Collect blood specimens for culture prior to starting antibiotic therapy.

Review medical record for results of a chest x-ray taken on admission.

Answer and Explanation

The Correct Answer is C

Choice A reason: Monitoring the metabolic panel detects antibiotic side effects like renal toxicity, but this is ongoing. Collecting blood cultures first identifies the HAP pathogen, ensuring targeted therapy. Premature antibiotics may obscure results, leading to resistance, making cultures more urgent for effective treatment of this nosocomial infection.

Choice B reason: Nebulizer treatments aid airway clearance in HAP, but identifying the pathogen via cultures is critical before antibiotics. Ineffective therapy delays recovery, as bacteria proliferate in mucus. Cultures guide precise antibiotic selection, reducing resistance risk, making this less immediate than obtaining microbiological data.

Choice C reason: Collecting blood cultures before antibiotics identifies the HAP pathogen (e.g., MRSA) and its sensitivity, critical for tailoring therapy. Broad-spectrum antibiotics can yield false-negative cultures, complicating treatment. This ensures accurate diagnosis, optimizing outcomes in severe infections, addressing the microbiological basis of HAP management.

Choice D reason: Reviewing chest x-ray confirms HAP with infiltrates but does not guide immediate antibiotic therapy. Cultures are urgent to identify the pathogen before antibiotics, as x-rays are non-specific and already documented. Cultures ensure pathogen-specific treatment, critical for combating hospital-acquired infections effectively.

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Correct Answer is D

Explanation

Choice A reason: Delaying smoking for one hour is arbitrary and does not address smoking’s risks post-surgery. Nicotine causes vasoconstriction, reducing wound perfusion, and carbon monoxide impairs oxygen delivery, delaying healing. Advising against smoking mitigates these risks, promoting recovery, making this response less effective than cessation advice.

Choice B reason: Allowing smoking in a wheelchair ignores postoperative risks. Nicotine’s vasoconstriction reduces tissue oxygenation, and carbon monoxide lowers hemoglobin’s capacity, impairing healing. This increases infection or thrombosis risk. Advising against smoking addresses these physiological harms, prioritizing wound recovery over facilitating smoking, which is detrimental.

Choice C reason: Smoking in the room violates hospital safety and exposes others to secondhand smoke. Nicotine and carbon monoxide reduce tissue perfusion and oxygen delivery, delaying postoperative healing. Advising against smoking prevents these complications, ensuring better recovery, making this response unsafe and inappropriate for surgical patients.

Choice D reason: Advising against smoking is critical, as nicotine causes vasoconstriction, reducing blood flow to surgical sites, and carbon monoxide impairs oxygen delivery, delaying healing. These increase infection and thrombosis risks post-surgery. This response promotes optimal recovery, addressing physiological needs for wound healing in the critical 24-hour period.

A. Elevate the client’s right hand on one or two pillows. B. Measure the client’s blood pressure and apical heart rate. C. Complete a neurovascular assessment of the right hand. D. Notify the healthcare provider quickly.

Correct Answer is C

Explanation

Choice A reason: Elevating the hand reduces edema, potentially improving circulation, but is premature without assessing the absent radial pulse’s cause. Post-fracture, compartment syndrome or arterial injury risks ischemia. Neurovascular assessment identifies severity, guiding targeted interventions to restore perfusion, making elevation secondary to assessment.

Choice B reason: Measuring blood pressure and heart rate provides systemic data but not localized insight into the absent radial pulse, likely from arterial compression post-surgery. Neurovascular assessment evaluates limb perfusion, detecting compartment syndrome or occlusion, critical for urgent intervention to prevent tissue necrosis.

Choice C reason: Completing a neurovascular assessment evaluates pulse, color, warmth, sensation, and movement. Absent radial pulse post-fracture suggests compartment syndrome or arterial injury, risking ischemia. This confirms vascular compromise, guiding interventions like fasciotomy, addressing the pathophysiological threat to limb viability, ensuring timely treatment.

Choice D reason: Notifying the provider follows assessment. Absent radial pulse suggests compartment syndrome, where swelling impairs arterial flow. Neurovascular assessment quantifies severity (e.g., pallor, paresthesia), ensuring accurate reporting for urgent intervention, preventing delays in treating vascular compromise critical to limb preservation.

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The healthcare provider writes several prescriptions for a client diagnosed with hospital-acquired pneumonia (HAP) that include a combination of broad-spectrum antibiotics. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse discontinues a 24-hour postoperative client’s patient-controlled analgesia (PCA) pump, the client asks to go to the hospital’s smoking area to smoke a cigarette. Which response should the nurse provide?

Correct Answer is D

Explanation

Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the client’s right radial pulse. Which action should the nurse take first?

Correct Answer is C

Explanation

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