The nurse is preparing to make rounds after receiving shift report. Which client should the nurse assess first?

Correct Answer: A

Rationale: In this scenario, the nurse should assess the client with end-stage COPD reporting shortness of breath (SOB) after ambulating to the bathroom first (Option A). This choice is correct because patients with end-stage COPD are at high risk for respiratory distress, and any increase in SOB could indicate a worsening of their condition requiring urgent intervention. Option B is incorrect because while a client with DVT requesting an anti-anxiety medication may need attention, it is not as urgent as a potential respiratory distress situation in a client with end-stage COPD. Option C is also incorrect as the client diagnosed with pneumonia needing a sputum specimen to be taken to the lab does not present an immediate threat to their health compared to the client with worsening SOB. Option D is incorrect as well because although the client with empyema has vital sign changes, those changes are not as indicative of an immediate life-threatening situation as the client with end-stage COPD experiencing increased SOB. This educational context highlights the importance of prioritizing patient care based on the urgency of the situation. Understanding the specific needs and risks associated with different conditions helps nurses make quick and accurate decisions to ensure patient safety and well-being.

Correct Answer: B

Rationale: In this scenario, the best response for the nurse when a client receiving oxygen therapy via nasal cannula reports nasal dryness is option B) Apply water-soluble lubricant to the nostrils. The rationale behind choosing this option is that nasal dryness is a common side effect of oxygen therapy through a nasal cannula due to the drying effect of the oxygen flow. Applying a water-soluble lubricant helps to moisturize the nasal passages, alleviating dryness and discomfort for the client. Option A is incorrect because increasing the oxygen flow rate can exacerbate nasal dryness rather than alleviate it. It may lead to further discomfort and potential harm to the nasal mucosa. Option C suggests switching to a simple face mask, which is not necessary if the issue is only nasal dryness. Face masks may not be well tolerated by all clients and can be uncomfortable for prolonged use. Option D is not the best response as encouraging the client to breathe through their mouth does not address the underlying issue of nasal dryness caused by oxygen therapy. Moreover, mouth breathing may not be as effective in oxygen delivery for some individuals. Educationally, this question highlights the importance of assessing and managing side effects of oxygen therapy, promoting critical thinking in nursing interventions, and understanding the rationale behind each response to provide safe and effective care for clients undergoing oxygen therapy.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Administering antipyretics as prescribed. In a client with pneumonia experiencing a high fever and diaphoresis, the priority intervention is to address the fever to prevent complications such as dehydration, increased metabolic demand, and discomfort. Antipyretics help reduce the fever and alleviate discomfort, promoting comfort and aiding in recovery. Option B) Encouraging oral fluid intake is important for hydration but addressing the fever takes precedence as dehydration can occur rapidly with a high fever. Option C) Obtaining a sputum culture is important for identifying the causative organism of the pneumonia but does not address the immediate need of managing the fever. Option D) Applying cool compresses to the forehead can provide comfort but does not address the underlying cause of the fever, which needs to be managed to prevent complications. In an educational context, understanding the priority interventions in a client with pneumonia and fever is crucial for providing safe and effective care. Addressing acute symptoms promptly can prevent further deterioration and promote positive outcomes for the client. Prioritizing interventions based on the client's condition and immediate needs is a fundamental aspect of nursing practice.

Correct Answer: A

Rationale: In the context of a client with pneumonia prescribed antibiotics, the priority nursing intervention is administering the antibiotics on time (Option A). This is crucial because timely administration ensures that the prescribed treatment is effective in combating the infection and preventing its spread. Encouraging the client to complete the full course of antibiotics (Option B) is important for preventing antibiotic resistance and ensuring complete eradication of the infection. However, in terms of immediate priority, timely administration takes precedence. Monitoring for signs of allergic reaction after administration (Option C) is essential for client safety but is not the immediate priority compared to ensuring the administration of the prescribed treatment. Documenting the client's response to treatment (Option D) is important for tracking progress and evaluating the effectiveness of the antibiotics. However, this falls secondary to the critical need for timely administration to address the active infection promptly. In an educational context, understanding the rationale behind prioritizing interventions helps nurses develop critical thinking skills necessary for making quick and effective decisions in clinical practice. Emphasizing the significance of timely medication administration underscores the importance of adherence to treatment protocols to achieve positive patient outcomes.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D: Collecting a sputum culture. The priority for a client with pneumonia exhibiting a productive cough and fever is to identify the causative organism through a sputum culture. This will guide appropriate antibiotic therapy, crucial for effective treatment of pneumonia. Option A (Encouraging fluid intake) is important for maintaining hydration but is not the priority when the client's condition requires immediate intervention for diagnosis and treatment. Option B (Administering antipyretics) addresses the fever symptomatically but does not address the underlying cause. Option C (Performing chest physiotherapy) may be beneficial in mobilizing secretions but is not the priority over identifying the infectious agent causing the pneumonia. Educationally, this question highlights the importance of critical thinking in prioritizing interventions based on the client's condition and the urgency of the situation. It emphasizes the significance of diagnostic procedures in guiding appropriate treatment and the role of nurses in clinical decision-making to ensure optimal patient outcomes.