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A nurse admits a client from the emergency department. Client data are listed below: History: 70 years of age, history of diabetes, on insulin twice a day. Physical Assessment: Crackles and rhonchi heard throughout the lungs, dullness to percussion LLL, afebrile, productive cough, oriented to person only. What action by the nurse is the priority?
- A. Administer oxygen at 2 liters per nasal cannula.
- B. Begin broad-spectrum antibiotics.
- C. Collect a sputum sample for a culture.
- D. Start an IV of normal saline at 50 mL/hr.
Correct Answer: A
Rationale: All actions are appropriate for this client who has manifestations of pneumonia. However, airway and breathing come first, so beginning oxygen administration to maintain saturation greater than 95% is the priority.
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A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority? (Select all that apply.)
- A. 22-year-old client with asthma.
- B. Client who had a cholecystectomy last year.
- C. Client with well-controlled diabetes.
- D. Healthy 72-year-old client.
- E. Client who is taking medication for hypertension.
Correct Answer: A,C,D,E
Rationale: Clients over 65 years of age and any client with a chronic health condition (e.g., asthma, diabetes, hypertension) are considered a priority for a pneumonia vaccination. A cholecystectomy does not qualify as a chronic health condition.
A nurse working in a geriatric clinic sees clients with cold symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms?
- A. Chlorphenamine (Chlor-Trimeton)
- B. Diphenhydramine (Benadryl)
- C. Fexofenadine (Allegra)
- D. Hydroxyzine (Vistaril)
Correct Answer: C
Rationale: First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorphenamine, diphenhydramine, and hydroxyzine. Fexofenadine is a second-generation antihistamine, which is safer and more suitable for older adults.
A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important?
- A. Are any family members also ill?
- B. Have you traveled recently?
- C. How long have you been ill?
- D. What is your occupation?
Correct Answer: D
Rationale: Inhalation anthrax is rare and is an occupational hazard among people who work with animal wool, bone meal, hides, and such, such as tanners and veterinarians. Inhalation anthrax in someone without an occupational risk is considered a bioterrorism event and must be reported to authorities immediately.
A client is in the family practice clinic reporting a severe cold that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best?
- A. Educate the client on oseltamivir (Tamiflu).
- B. Facilitate admission to the hospital.
- C. Instruct the client to have a flu vaccine.
- D. Teach the client to sneeze in the upper sleeve.
Correct Answer: D
Rationale: Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. Given the client's symptoms and the need to prevent further transmission, this is the most appropriate action.
A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate?
- A. Arrange for immediate hospitalization.
- B. Facilitate polymerase chain reaction testing.
- C. Have the client produce a sputum sample.
- D. Obtain two sets of blood cultures.
Correct Answer: B
Rationale: Polymerase chain reaction testing is used to diagnose pertussis, which this client is showing manifestations of. This is the most appropriate action to confirm the diagnosis.