Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
51. Which is the most important initial nursing action for a client with community-acquired pneumonia?
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
51. Which is the most important initial nursing action for a client with community-acquired pneumonia?
. Maintain IV site used for antibiotic therapy.
. Assess for indications of antibiotic effectiveness.
. Assist with client mobility.
. Assess for pain and treat as ordered.
Test-Taking Tip
This is a priority question. All of the options may be correct but one is priority. The sooner the antibiotics are started, the sooner the client will be ambulating and breathing comfortably.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Planning; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Illness Management
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
.
Answer 1 is correct because antibiotic therapy is the most important aspect of treatment. Maintaining IV site patency and integrity is a key role for the RN and for the client's recovery. Answer 2 is incorrect because the antibiotics must be administered through a patent site before effectiveness can be evaluated. Answer 3 is incorrect because this is not the first action, although mobility is important in improving respiratory function. Answer 4 is incorrect because IV therapy is the first priority, but the client's comfort is important as pain will affect respiratory status.