A client with a productive cough has obtained a sputum specimen for culture as
instructed. What is the best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis
B. Observe the color, consistency, and amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary
resuscitation (CPR) in progress. The client is intubated and is receiving 100%
oxygen per self-inflating (ambu) bag. The nurse determines that the client is
cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to
obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature
A. Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH),
a client develops pontine myselinolysis. Which intervention should the nurse
implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises
A. Reorient client to his room
A male client with heart failure (HF) calls the clinic and reports that he cannot put his
shoes on because they are too tight. Which additional information should the nurse
obtain?
A. What time did he take his last medications?
B. Has his weight changed in the last several days?
C. Is he still able to tighten his belt buckle?
D. How many hours did he sleep last night?
B. Has his weight changed in the last several days?
An older adult woman with a long history of chronic obstructive pulmonary disease
(COPD) is admitted with progressive shortness of breath and a persistent cough.
She is anxious and is complaining of a dry mouth. Which intervention should the
nurse implement?
A. Administer a prescribed sedative
B. Encourage client to drink water
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