A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

Administer the prescribed antipyretic and notify the primary health care provider.

Assess the color and content of the urine specimen for urinalysis.

Note the consistency of respiratory secretions and obtain a specimen for culture.

Compare all prior vital signs and continue to monitor every hour.

Answer and Explanation

The Correct Answer is A

Choice A reason: Administering an antipyretic to reduce the fever and notifying the primary health care provider are the priority actions. A rapid rise in temperature in a client with multiple myeloma receiving chemotherapy could indicate a serious infection, which requires prompt medical attention.

Choice B reason: Assessing the color and content of the urine specimen for urinalysis is important but is not the immediate priority. The rapid rise in temperature is a more urgent concern.

Choice C reason: Noting the consistency of respiratory secretions and obtaining a specimen for culture is important but not the immediate priority. The primary concern is addressing the fever and notifying the healthcare provider.

Choice D reason: Comparing prior vital signs and continuing to monitor every hour is necessary but not the immediate priority. Immediate action is required to address the fever and potential infection.

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Correct Answer is C

Explanation

Choice A reason: Pyridostigmine is used to treat myasthenia gravis, not for preventing Addisonian crisis in patients undergoing adrenalectomy. It is not related to adrenal hormone replacement.

Choice B reason: Tensilon (edrophonium) is used in the diagnosis of myasthenia gravis and is not relevant for managing adrenal insufficiency or preventing Addisonian crisis.

Choice C reason: Hydrocortisone intravenously is the correct choice for preventing Addisonian crisis in a client scheduled for adrenalectomy. Hydrocortisone provides the necessary corticosteroid replacement to manage the deficiency of adrenal hormones during and after surgery.

Choice D reason: Spironolactone is a potassium-sparing diuretic used to treat conditions like heart failure and hypertension. It is not used for preventing Addisonian crisis or managing adrenal insufficiency.

A. A patient with a new-onset of confusion and restlessness. B. A patient who reports dizziness after receiving captopril (Capoten). C. A patient who requires oxygen via nasal cannula with saturations of 97%. D. A patient who has received digoxin and has a blood pressure (BP) of 100/56.

Correct Answer is A

Explanation

Choice A reason: A patient with a new-onset of confusion and restlessness is a priority because these symptoms could indicate a serious condition such as hypoxia, electrolyte imbalance, or a neurological event like a stroke. These changes in mental status need to be evaluated immediately to prevent further complications.

Choice B reason: Dizziness after receiving captopril (Capoten) can be a side effect of the medication due to its blood pressure-lowering effects. While it should be monitored, it is not as urgent as the new-onset confusion and restlessness seen in another patient.

Choice C reason: A patient requiring oxygen via nasal cannula with saturations of 97% is stable as the oxygen saturation is within normal limits. This patient does not need to be prioritized over others with more acute symptoms.

Choice D reason: A patient who has received digoxin and has a blood pressure of 100/56 should be monitored, especially for signs of digoxin toxicity. However, this situation is not as critical as the new-onset confusion and restlessness in another patient.

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A client with multiple myeloma receiving chemotherapy has a temperature of 102.2 degrees Fahrenheit. The temperature was 99.2 degrees Fahrenheit six hours ago. The PRIORITY nursing intervention is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is scheduled for an adrenalectomy. The nurse plans to administer which medication in the preoperative period to prevent Addisonian Crisis?

Correct Answer is C

Explanation

The night nurse in the cardiac ICU has just received a report on several patients. Which of the following clients should the nurse prioritize for rounds?

Correct Answer is A

Explanation

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