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 B
Explanation
This is the best intervention for the PN to implement because it relieves the muscle spasm and reduces the pain of a leg cramp. Leg cramps are common during pregnancy and labor due to changes in calcium levels, fluid balance, or pressure on nerves and blood vessels.
A. Massaging the calf and foot is not recommended because it may increase pain or cause injury to the muscle or nerve.
C. Checking the pedal pulse in the affected leg is not necessary unless there is a suspicion of vascular compromise or thrombosis, which are unlikely causes of a leg cramp.
D. Elevating the leg above the heart is not helpful because it may impair blood flow or increase pressure on the nerve or muscle.
Correct Answer is A
Explanation
The correct answer is choice A: Record the findings and report the symptoms to the charge nurse.
Choice A rationale:
The practical nurse (PN) should first record the client's findings, including the progressively decreasing appetite, increased daytime bed hours, and refusal to participate in planned activities. This documentation is essential for accurate communication and continuity of care. After recording the findings, the PN should promptly report the symptoms to the charge nurse. Reporting allows for timely intervention and assessment by the charge nurse or other healthcare providers to address the client's issues effectively.
Choice B rationale:
Asking family members to visit more often is not the best action to take in this situation. While family support is important, the client's symptoms suggest possible underlying health concerns that need professional evaluation and management. Relying solely on increased family visits might delay appropriate healthcare interventions.
Choice C rationale:
Motivating the client by offering their favorite foods as a prize might not be appropriate at this stage. The client's decreased appetite and refusal to participate in activities could be indicators of underlying health issues that need to be addressed first. Moreover, encouraging unhealthy eating habits as a "prize”. could be counterproductive to the client's well-being.
Choice D rationale:
Withholding medications that may cause side effects is not a suitable action without consulting the healthcare provider responsible for the client's care. Abruptly stopping medications could lead to adverse effects or complications, and it is essential to involve the healthcare team in making decisions about medication management.
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