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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 fo - 🧠 ANSWER ✔✔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 - 🧠 ANSWER ✔✔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 - 🧠 ANSWER ✔✔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?
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, D. How many hours did he sleep last night? - 🧠 ANSWER ✔✔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
C. Apply a high-flow venturi mask
D. Assist her to an upright position - 🧠 ANSWER ✔✔D. Assist her to an
upright position
A client with a history of asthma and bronchitis arrives at the clinic with
shortness of breath, productive cough with thickened tenacious mucous,
and the inability to walk up a flight of stairs without experiencing
breathlessness. Which action is most important for the nurse to instruct the
client about self-care?