The practical nurse (PN) notes that an older female client has developed a nonproductive cough and seems more confused than the previous day. Vital signs are temperature 99.8°F (37.66°C); pulse 94; respirations 22; and blood pressure (BP) 108/54. Which intervention is most important for the PN to implement?

Monitor the client's temperature hourly.

Offer the client fluids frequently.

Provide care to moisten oral mucosa.

Report the findings to the charge nurse.

Answer and Explanation

The Correct Answer is D

Correct Answer: D. Report the findings to the charge nurse.

Choice A rationale:

Monitoring the client's temperature hourly may be indicated if the client's condition deteriorates or if there are specific concerns about fever. However, the temperature of 99.8°F (37.66°C) is not significantly elevated and may not be the primary concern in this situation.

Choice B rationale:

Offering the client fluids frequently is a good nursing practice, but it is not the most important intervention in this case. The client's nonproductive cough and increased confusion need to be addressed and reported first.

Choice C rationale:

Providing care to moisten oral mucosa is important for maintaining oral health and preventing dryness and discomfort. However, it may not directly address the client's current symptoms of cough and confusion.

Choice D rationale:

Reporting the findings to the charge nurse is the most crucial intervention. The client's nonproductive cough and increased confusion may be indicative of an underlying issue, such as a respiratory infection or a change in neurological status. The charge nurse can initiate further assessments, notify the healthcare provider, and implement appropriate interventions to address the client's condition promptly. Timely reporting and communication are essential to ensure the client receives appropriate care.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

This is the best action that describes the responsibility of the PN because it ensures that the client has given informed consent for the invasive examination and that the consent form is valid and documented. The PN should verify that the provider has explained the examination, its risks and benefits, and alternative options to the client and that the client has agreed to proceed.

A. Obtain the infant's vital signs. B. Administer vitamin K injection. C. Place the ID bands on the infant and mother. D. Observe the infant latching onto the breast.

Correct Answer is C

Explanation

The correct answer is Choice C. Place the ID bands on the infant and mother.

Choice A rationale:

While obtaining the infant's vital signs is important, it is not the priority action before transporting the baby to the nursery. Placing ID bands on the infant and mother ensures proper identification and prevents mix-ups during transportation, which is crucial in the nursery setting.

Choice B rationale:

Administering vitamin K injection is also essential but not the immediate priority before transporting the baby. Vitamin K administration helps prevent bleeding disorders in newborns, but ensuring proper identification and security come first.

Choice C rationale:

The correct choice. Placing ID bands on the infant and mother is the most important action before transporting the baby to the nursery. This step ensures accurate identification and matching between the baby and the mother, preventing any confusion or errors in the hospital setting.

Choice D rationale:

Observing the infant latching onto the breast is important for promoting breastfeeding, but it can be done after ensuring proper identification and safety measures have been taken.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

Correct Answer is D

Explanation

A practical nurse (PN) who works in the nursery is attending the vaginal delivery of a term infant. Which action should the PN complete prior to transporting the baby to the nursery?

Correct Answer is C

Explanation

At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the PN take?

What is most important for the practical nurse (PN) to include when performing pain assessment after giving an analgesic?

The practical nurse (PN) administers an injection using a syringe with a retractable needle. After the needle is removed from the client's skin, the needle does not retract, and the PN gets stuck in the finger with the used needle. What action should the PN take first?

The practical nurse (PN) is preparing for shift change. Which task has the highest priority and should be completed first?

The practical nurse (PN) is assigning care for a group of clients on the urology medical unit. Which client care interventions should the PN assign to the unlicensed assistive personnel (UAP)? (Select all that apply.).