A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the
best initial nursing action?
A. Administer the first dose of antibiotic therapy
B. Observe the color, consistency, and amount of sputum
C. Encourage the client to consume plenty of warm liquids
D. Send the specimen to the lab for analysis Correct Answer: B. Observe the color, consistency, and
amount of sputum
A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in
progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse
determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the
nurse to obtain?
A. Breath sounds over bilateral lung fields.
B. Carotid pulsation during compressions
C. Deep tendon reflexes
D. Core body temperature Correct Answer: A. Breath sounds over bilateral lung fields.
After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops
pontine myselinolysis. Which intervention should the nurse implement first?
A. Reorient client to his room
B. Place a patch on one eye
C. Evaluate client's ability to swallow
D. Perform range of motion exercises Correct Answer: A. Reorient client to his room
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