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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Correct Answer is D

Explanation

d. Escort the client to a calm and quiet place.

The PN should use a calm and firm approach to de-escalate the situation and remove the client from the stressful environment. This can help prevent further agitation and potential violence.

The other options are not correct because:

Instructing a UAP to stay with the client may not be eﬀective or safe, as the UAP may not have the skills or training to handle an agitated client.
Notifying the client's healthcare provider is not a priority action, as it does not address the immediate safety of the client and others.
Administering a PRN medication for agitation may be indicated, but it is not the first action. The PN should try non- pharmacological interventions first, unless there is an imminent risk of harm.

A. Risk for infection B. Ineffective airway clearance C. Acute pain D. Disturbed body image

Correct Answer is B

Explanation

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients. Which action should the practical nurse (PN) implement first?

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

The practical nurse (PN) is assisting with the admission of a client with complications of left- sided heart failure. Which focused assessment should the PN implement first?

An unlicensed assistive personnel (UAP) is completing an orientation assignment and is caring for a client who needs assistance with bathing. What is the best way for the practical nurse (PN) to evaluate this UAP's performance?

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?

A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

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

The unlicensed assistive personnel (UAP) tells the practical nurse (PN) that a male client is angry because the night shift took over 2 hours to bring him the pain medication he had to request three times. Which action should the PN implement first?

A client with urinary and fecal incontinence has an increased risk for developing a sacral pressure ulcer. Which information should the practical nurse (PN) give the unlicensed assistive personnel (UAP) who is assisting with the care of the client?