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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Red welts widespread over the chest.
Choice A rationale:
Ulceration on the corner of the upper lip does not indicate a need for loratadine administration. Loratadine is an antihistamine commonly used to relieve symptoms of allergies such as sneezing, runny nose, and itchy or watery eyes. Ulceration on the lip is not associated with an allergic reaction.
Choice B rationale:
Ecchymosis and petechiae on the legs are not related to the need for loratadine. These findings suggest potential bleeding or clotting disorders, and loratadine does not address such issues.
Choice C rationale:
Red welts widespread over the chest are indicative of hives (urticaria), which are often caused by allergic reactions. Loratadine can help alleviate the symptoms of hives by blocking histamine release, making it an appropriate choice for this condition.
Choice D rationale:
Red papules and pustules on the face are unlikely to be treated with loratadine. These skin manifestations may be related to various dermatological conditions, but not necessarily allergic reactions that loratadine is primarily used to manage.
Correct Answer is B
Explanation
This is the best initial intervention for the PN to implement because it promotes comfort, relaxation, and circulation for the client. A back rub can also reduce anxiety and muscle tension, which can interfere with sleep. The PN should use non-pharmacological methods to facilitate sleep before resorting to medication.
A. Offering the client a prescribed sleep medication is not the best initial intervention because it may have side effects or interactions with other drugs. The PN should assess the client's need for medication and use it as a last resort.
C. Administering an as-needed (PRN) prescription for pain is not the best initial intervention because it may not address the cause of the client's difficulty in sleeping. The PN should assess the client's pain level and use other methods to relieve pain before giving medication.
D. Providing a cup of hot chocolate at bedtime is not the best initial intervention because it may contain caffeine, which can stimulate the central nervous system and keep the client awake. The PN should avoid giving caffeinated beverages to the client before bedtime.
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