A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What actions would the nurse NOT take?

Correct Answer: A

Rationale: Correct Answer: A - Provide a clear liquid breakfast. Rationale: Preparing a client for a bronchoscopy with transbronchial biopsy involves NPO (nothing by mouth) after midnight to prevent aspiration during the procedure. Providing a clear liquid breakfast contradicts the NPO status required. Summary: - B: Verifying informed consent is essential to ensure the client understands the procedure and consents to it. - C: Documenting allergies is important to prevent any adverse reactions during the procedure. - D: Reviewing laboratory results is necessary to ensure the client's readiness for the procedure.

Correct Answer: A

Rationale: The correct answer is A because the client's presentation suggests an acute respiratory issue, likely pneumonia. The client has crackles and rhonchi, low WBC count, and new onset dyspnea and cough. The priority is to assess oxygenation (PaO2 of 85 mm Hg), which is crucial in pneumonia. The client is on insulin, so blood glucose monitoring is vital. The other choices are not the priority at this moment: B is not the priority until oxygenation is assessed, C is premature without a confirmed diagnosis, and D can be done after prioritizing oxygenation.

Correct Answer: A

Rationale: The correct answer is A. Nosocomial pneumonia specifically occurs in healthcare settings, often due to exposure to pathogens in hospitals or clinics. B (immunocompromised host) increases susceptibility but is not the defining feature. C (community setting) refers to community-acquired pneumonia. D (within 48 hours) applies to hospital-acquired pneumonia but not all nosocomial cases.

Correct Answer: D

Rationale: In the context of caring for a client with a pulmonary embolism (PE), the correct answer is D) Auscultate lung sounds for crackles. This task involves a specific skill set that falls within the scope of practice for an LPN/LVN. Auscultating lung sounds for crackles is crucial in assessing the respiratory status of the client, especially in cases of PE where there can be potential complications like pulmonary edema. Option A, evaluating the client's complaints of chest pain, involves a higher level of assessment and interpretation of symptoms, which is typically within the scope of a registered nurse or higher-level provider. Option B, monitoring lab values for changes in oxygenation, requires a deeper understanding of interpreting lab results and making clinical decisions based on those results, making it more appropriate for an RN. Option C, assessing for symptoms of respiratory failure, also involves a higher level of assessment and critical thinking skills that are generally within the RN's scope of practice. Providing this educational context helps clarify the specific roles and responsibilities of different members of the healthcare team based on their training and licensure levels.

Correct Answer: D

Rationale: The initial antibiotic treatment for pneumonia is typically based on the history, physical examination, and characteristic chest x-ray findings. This helps in identifying the specific causative organism and choosing the most appropriate antibiotic therapy. Gram stains and cultures may further confirm the diagnosis but are not typically used for initial treatment decisions.