The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?
Risk for infection
Ineffective airway clearance
Acute pain
Disturbed body image
The Correct Answer is B
The correct answer is choice B. Ineffective airway clearance.
Choice A rationale:
Risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the factor that the PN should consider the most likely to increase the client's risk for falls because it can cause orthostatic hypotension, dizziness, or fainting, especially when the client changes position or gets up from bed or a chair. The PN should monitor the client's blood pressure and pulse before and after administering the medication and assist the client with ambulation and transfers.
Correct Answer is ["B","C","D"]
Explanation
These are the information that the PN should obtain prior to administering pain medication to an adult postoperative client because they help to assess the client's current pain level, response to previous medication, and need for further intervention. The PN should also document this information in the medical record and report any changes or concerns.
A. Height and weight of client prior to admission are not relevant for administering pain medication and may not affect the dosage or route of the medication.
E. History of pain medication use during the past year is not relevant for administering pain medication and may not indicate the client's tolerance or preference for the medication.
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