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 B
Explanation
Digoxin is a medication used to treat various heart conditions, such as abnormal heart rhythms and heart failure.It works by improving the strength and efficiency of the heart, or by controlling the rate and rhythm of the heartbeat.
One of the important things to monitor when giving digoxin to an infant is the pulse rate. Digoxin can lower the heart rate, which can be dangerous if it becomes too slow.Therefore, the pulse rate should be checked for one full minute before administering digoxin, and the medication should be held if the pulse rate is below 90 beats per minute (bpm) for an infant.
In this case, the infant’s heart rate is 120 bpm, which is within the normal range for a 2-month-old. Therefore, the correct action for the PN to take is to administer the medication and document the heart rate. This is optionbin the list of choices. Optionais incorrect because there is no need to hold the medication or recheck the heart rate in one hour. Optioncis incorrect because there is no need to alert the charge nurse unless there is a problem with the infant’s condition or the medication. Optiondis incorrect because holding the medication and documenting cardiac assessment is not appropriate for a normal heart rate.
Correct Answer is D
Explanation
The correct answer is choice D: Provide fluid and electrolyte replacement. Choice A rationale:
Isolating all infectious diarrhea victims is not the highest priority in this situation. While it is essential to prevent the spread of cholera, immediate medical intervention to treat those affected takes precedence.
Choice B rationale:
Administering prophylactic antibiotics as prescribed is not the highest priority because it focuses on prevention rather than treatment. In the case of a cholera outbreak, it is more critical to address the immediate needs of those already diagnosed.
Choice C rationale:
Administering cholera vaccines may be part of a preventive strategy, but it is not the highest priority during an active cholera outbreak. Vaccination takes time to develop immunity, and the focus should be on treating those already affected.
Choice D rationale:
Providing fluid and electrolyte replacement is the highest priority in managing cholera. Cholera is characterized by severe diarrhea and dehydration, which can lead to life-threatening complications. Promptly restoring fluids and electrolytes helps prevent shock and organ failure.
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