A nurse is caring for a patient who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing PRIORITY?

Obtain a sputum culture

Obtain baseline vital signs and oxygen saturation

Obtain a complete history from the client

Provide the PCV vaccine

Answer and Explanation

The Correct Answer is B

A.   While obtaining a sputum culture is important for diagnosing a potential respiratory infection, it is not the immediate priority. The patient’s vital signs and oxygenation status need to be assessed first to ensure safety and to inform clinical decisions.
B.   Assessing the patient’s vital signs and oxygen saturation is critical in this situation. The symptoms of disorientation, chills, and chest pain could indicate a serious condition such as pneumonia or pulmonary embolism.
C.   Gathering a complete history is valuable for understanding the patient's condition and underlying causes of symptoms. However, this action should follow immediate assessments of vital signs and oxygen saturation, especially in a potentially unstable patient.
D.   Administering the pneumococcal vaccine is important for prevention but is not an urgent action in this acute situation. The patient’s current symptoms require immediate assessment and intervention rather than preventive measures.

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Correct Answer is ["A","B","D","E"]

Explanation

A. Using a filtered IV line helps remove any particulate matter that could be present in the TPN solution, reducing the risk of complications such as phlebitis or embolism.
B. TPN should have its own dedicated line to prevent incompatibilities and ensure the TPN solution is delivered without interference. Infusing other medications through the same line can lead to complications and reduce the effectiveness of TPN.
C. If TPN gets stopped or runs out, a bag of 5% dextrose in water (D5W) should be hung to prevent hypoglycemia. D10% is too concentrated and can cause hyperglycemia.
D. To minimize the risk of infection and maintain sterility, TPN bags and tubing should be replaced every 24 hours. This helps prevent bacterial growth in the TPN solution.
E. TPN is typically administered through a central line because it allows for the infusion of hypertonic solutions that can irritate peripheral veins. Central lines provide better access to larger blood vessels, reducing the risk of complications.

A. Morphine Sulfate 4 mg IV ATC B. Fentanyl 25 mcg/hr transdermal patch Now C. Ibuprofen 800 mg PO D. Hydromorphone liquid 5 mg PO

Correct Answer is A

Explanation

A. Morphine is a strong opioid analgesic that is effective for managing severe pain, especially in acute situations like a vaso-occlusive crisis. Administering it intravenously allows for rapid onset of pain relief, which is critical given the severity of the patient’s symptoms. Continuous dosing (ATC—around the clock) ensures that pain is managed effectively.
B. Fentanyl patches are typically used for chronic pain management and take time to reach effective levels in the bloodstream (up to 12 hours or longer). In the case of acute severe pain from a vaso- occlusive crisis, this option would not provide immediate relief.
C. While ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help relieve mild to moderate pain, it is not adequate for severe pain management. Additionally, in the setting of sickle cell disease, patients may be at risk for renal issues, making high doses of NSAIDs potentially harmful.
D. Hydromorphone is also a strong opioid analgesic; however, administering it orally may not be effective for severe pain management in an acute situation. IV administration of opioids is preferred for immediate and potent pain relief during a vaso-occlusive crisis.

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A nurse is caring for a patient who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing PRIORITY?

Nursing Test Bank

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Which of the following is are appropriate nursing interventions to ensure the safety of a patient who is receiving Total Parenteral Nutrition (TPN)? (Select all that apply)

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Explanation

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Correct Answer is A

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