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GRADED A+ \ACTUAL TEST BANK FINAL EXAM , BEST
DOCUMENT FOR EXAM PREPARATION WITH RATIONALES
A nurse is caring for a client who has pneumonia. Assessment findings include
temperature 37.8° C (100° F), respirations 30/min, blood pressure 130/76,
heart rate 100/min, and SpO2 91% on room air. Prioritize the following
nursing interventions.
Administer antibiotics
Administer oxygen therapy
Perform a sputum culture
Instruct the client to obtain a yearly influenza vaccination
1 Administer oxygen therapy
2 Perform a sputum culture
3 Administer antibiotics
4 Instruct the client to obtain a yearly influenza vaccination
The client’s respiratory and heart rates are elevated, and her oxygen
saturation is 91% on room air. Using the ABC priority framework, providing
oxygen is the first
intervention. Obtaining a sputum culture is the second nursing
intervention. It should be done prior to administering oral medications to
obtain an accurate
specimen. Administration of antibiotics is the third action the nurse should
take. The sputum culture should be obtained prior to antibiotic
administration. The last action the nurse should take is to instruct the
client to receive yearly influenza
vaccinations, to reduce the risk of acquiring influenza that can lead to
pneumonia.
,A nurse is assessing a client who has a history of asthma. Which of the
following factors should the nurse identify as a risk for asthma?
A Males (sex assigned at birth)
B Environmental allergies
C Alcohol use
D History of diabetes
B Environmental allergies
Environmental allergies are a risk factor associated with asthma. A client
who has environmental allergies typically has other allergic problems,
such as rhinitis or a skin rash.
,A nurse in the emergency department is caring for a client who is
experiencing an acute asthma attack. Which of the following findings
indicates that the client’s
respiratory status is declining? Select all that apply.
A SpO2 95%
B Wheezing
C Retraction of sternal muscles
D Pink mucous membranes
E Tachycardia
B Wheezing
C Retraction of sternal muscles
E Tachycardia
Wheezing indicates narrowing of the airway and is a finding that could
indicate that the client’s respiratory status is declining. Retraction of
sternal muscles is associated with increased work of breathing and is a
finding that could indicate that the client’s respiratory status is declining.
Tachycardia is a finding that caused by decreased oxygenation and is a
finding that could indicate that the client’s respiratory status is declining.
, A nurse is assessing a client who has an SpO2 of 91%, audible wheezes and
is using accessory muscles when breathing. Which of the following
classes of medications should the nurse anticipate a provider
prescription?
A Third-generation cephalosporin
B Beta-blocker
C Nonsteroidal anti-inflammatory
D Short-acting beta 2 agonist
D Short-acting beta 2 agonist
The nurse should anticipate a provider prescription for a short-acting beta2
agonist, which is administered to cause dilation of the bronchioles, opening
of airways which reduces wheezing.
A nurse is providing discharge teaching to a client who has asthma and
received a new prescription for prednisone. Which of the following client
statements indicates understanding?
A “I will decrease my fluid intake while taking this medication.”
B “I will expect to have black, tarry stools.”
C “I will take my medication with meals.”
D “I will monitor for weight loss while on this medication.”
C “I will take my medication with meals.”
Prednisone is a corticosteroid that is used to manage inflammation for a
client who has asthma. The client should be informed to take prednisone
with food because taking it on an empty stomach can cause
gastrointestinal distress.