a nurse is caring for a client with pneumonia who has a new prescription for antibiotics which of the following actions should the nurse take first

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

1. A nurse is caring for a client with pneumonia who has a new prescription for antibiotics. Which of the following actions should the nurse take first?

A. Administer the antibiotic immediately
B. Obtain a sputum culture
C. Notify the provider of the prescription
D. Check the client's allergy history

Correct answer: B

Rationale: The correct first action for the nurse to take when caring for a client with pneumonia who has a new prescription for antibiotics is to obtain a sputum culture. This is important to identify the specific bacteria causing the pneumonia before administering antibiotics. Administering the antibiotic immediately (Choice A) may not be appropriate without knowing the specific pathogen. Notifying the provider of the prescription (Choice C) is important but not the first action to be taken. Checking the client's allergy history (Choice D) is relevant but not the priority in this situation.

2. Which question is essential during screening for alcohol use disorder?

A. What is your current employment status?
B. Have you experienced any blackouts or loss of consciousness?
C. Have you been sleeping well over the past month?
D. Do you have a family history of substance use?

Correct answer: B

Rationale: The essential question during screening for alcohol use disorder is asking about blackouts or loss of consciousness, which can be indicative of excessive drinking and related to alcohol use disorder. Choices A, C, and D are not as directly related to screening for alcohol use disorder. Employment status (Choice A) is not a primary question in alcohol use disorder screening. Sleep quality (Choice C) and family history of substance use (Choice D) may be relevant but are not as crucial as inquiring about blackouts or loss of consciousness.

3. Which finding in a postoperative patient requires immediate intervention by the nurse?

A. Heart rate of 88 beats per minute.
B. Blood pressure of 130/80 mmHg.
C. Crackles heard in the lung bases.
D. Oxygen saturation of 88% on room air.

Correct answer: D

Rationale: In a postoperative patient, an oxygen saturation level of 88% on room air indicates a significant drop below the normal range, suggesting potential respiratory distress. This finding requires immediate intervention by the nurse to ensure the patient receives adequate oxygenation. A heart rate of 88 beats per minute is within the normal range, making it a less concerning finding. A blood pressure of 130/80 mmHg falls within the normal range for blood pressure and does not require immediate intervention. Crackles heard in the lung bases may indicate fluid accumulation but may not always require immediate intervention unless accompanied by other concerning signs or symptoms.

4. What should be done to manage a patient with contact precautions?

A. Wear a mask, gown, and gloves for all patient interactions.
B. Ensure that visitors wear protective equipment.
C. Dedicate all patient care equipment to that patient.
D. Disinfect shared equipment before use.

Correct answer: C

Rationale: When managing a patient with contact precautions, it is essential to dedicate all patient care equipment to that specific patient. This practice helps minimize the risk of spreading infections to other patients. Choice A, wearing protective gear for all patient interactions, is a general precaution but not specific to managing a patient with contact precautions. Choice B, ensuring visitors wear protective equipment, is important for infection control but not directly related to managing the patient with contact precautions. Choice D, disinfecting shared equipment before use, is a good practice for infection control in general but does not address the specific needs of a patient under contact precautions.

5. How can dehydration be assessed in an elderly patient?

A. Checking skin turgor on the forearm
B. Assessing for dry mucous membranes
C. Checking for orthostatic hypotension
D. Measuring daily weights

Correct answer: A

Rationale: Assessing skin turgor by gently pinching the skin on the forearm is a reliable method to check for dehydration in elderly patients. When the skin is slow to return to its original position, it indicates dehydration. While assessing for dry mucous membranes is also important, checking skin turgor is a more direct method for dehydration assessment. Checking for orthostatic hypotension is more related to circulation status than dehydration. Measuring daily weights is helpful to monitor fluid balance but may not be as immediate or direct in detecting dehydration in elderly patients.