Nokea
A client is admitted with suspected pneumonia from the emergency department. The client went to the primary health care provider a few days ago" and shows the nurse the results of what the client calls an allergy test" as shown below: The reddened area is firm. What action by the nurse is best?
- A. Call the primary health care provider's office to request records.
- B. Immediately place the client on Airborne Precautions.
- C. Prepare to begin administration of intravenous antibiotics.
Correct Answer: C
Rationale: The correct answer is C: Prepare to begin administration of intravenous antibiotics. This is the best action because the client is suspected of having pneumonia, which is commonly treated with antibiotics. The nurse should prepare to start IV antibiotics to address the infection promptly.
Choice A is incorrect because requesting records from the primary health care provider's office may delay treatment. Choice B is incorrect because airborne precautions are not necessary for suspected pneumonia. Choice D is incomplete and does not provide a clear action plan for addressing the client's condition.
You may also like to solve these questions
Severing the sensory fibers from the lungs would result in all of the following except
- A. less inhibition of the inspiratory center during forced breathing
- B. a drop in tidal volume
- C. potential damage to the lungs due to overinflation
- D. a disappearance of the Hering-Breuer reflexes
Correct Answer: B
Rationale: The correct answer is B: a drop in tidal volume. Severing sensory fibers from the lungs would lead to decreased feedback to the brain, resulting in less inhibition of the inspiratory center and potentially overinflation of the lungs (choice C). The Hering-Breuer reflexes, responsible for preventing lung over-inflation, would disappear (choice D). However, tidal volume is primarily controlled by the respiratory muscles and respiratory center in the brain, not solely by sensory input from the lungs. Hence, severing sensory fibers would not directly lead to a drop in tidal volume.
A female adult client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
- A. 15 to 60 seconds.
- B. 5 to 20 minutes.
- C. 30 to 40 minutes.
- D. 45 to 60 minutes.
Correct Answer: B
Rationale: The correct answer is B: 5 to 20 minutes. Plugging the tracheostomy tube for this duration allows the client to gradually adapt to breathing without the assistance of the tube. Initially, the client may experience increased respiratory effort, which helps improve lung function. Plugging the tube for too short a time (A) may not provide enough challenge for the client, while plugging it for too long (C, D) may cause distress or potential complications due to lack of oxygen. Therefore, the optimal time frame of 5 to 20 minutes ensures a safe and effective weaning process for the client.
When obtaining a health history from a 76-year-old patient with suspected CAP, what does the nurse expect the patient or caregiver to report?
- A. Confusion
- B. An abrupt onset of fever and chills
- C. A recent loss of consciousness
- D. A gradual onset of headache and sore throat
Correct Answer: B
Rationale: In patients with Community-Acquired Pneumonia (CAP), an abrupt onset of fever and chills is a common symptom to expect. This is due to the rapid inflammatory response in the lungs. Confusion, loss of consciousness, and gradual headache and sore throat are less likely to be reported initially.
The nurse is caring for a first-day postoperative thoracotomy patient. The nurse assesses that
the level of drainage has not increased over the last 3 hours. After assessing the patient’s
respiratory status, what should the nurse do next?
- A. Raise the system above the patient's heart.
- B. Check the tubing for kinks.
- C. Reposition the patient.
- D. Notify the physician.
Correct Answer: B
Rationale: The correct answer is B: Check the tubing for kinks. This is the best next step because stagnant drainage could be caused by a kink in the tubing, obstructing proper drainage. By checking for kinks, the nurse ensures proper functioning of the drainage system, preventing potential complications such as fluid buildup or infection.
Raising the system above the patient's heart (A) may not address the underlying issue of kinked tubing. Repositioning the patient (C) may not be necessary if the drainage is not related to patient positioning. Notifying the physician (D) should be done after checking the tubing for kinks, as it is important to troubleshoot and address the issue promptly.
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first?
- A. Document the findings.
- B. Administer oxygen therapy.
- C. Position the client in high-Fowler position.
- D. Administer prescribed albuterol.
Correct Answer: A
Rationale: The correct action is to document the findings first because the harsh hollow sound over the trachea and larynx could indicate a potential issue with the airway or respiratory function. Documenting the findings allows for accurate communication with other healthcare providers and helps track changes in the client's condition. Administering oxygen therapy or albuterol should not be done without further assessment or orders from a healthcare provider. Positioning the client in high-Fowler position may not be the priority until a more thorough assessment is completed.