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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Leukocytosis refers to an elevated white blood cell (WBC) count, typically above the normal range (approximately 4,000 to 10,000 WBCs per microliter of blood). A count of 22,000 indicates leukocytosis, which may be due to infection, inflammation, stress, or other conditions.
B. A left shift refers to an increase in immature white blood cells, particularly neutrophil precursors, in the bloodstream. It often indicates an acute infection or inflammatory response. While the WBC count of 22,000 may suggest a left shift, it does not confirm it without further analysis of the differential count of the WBCs.
C. Erythrocytosis is an increase in red blood cells (RBCs), not white blood cells. Therefore, this option is incorrect. A high WBC count does not indicate changes in red blood cell levels.
D. Neutropenia refers to a decreased number of neutrophils, which are a type of white blood cell. Given the WBC count of 22,000, neutropenia is not applicable and is therefore incorrect.
Correct Answer is A
Explanation
A. A sudden new pain in a patient with SCD can be a sign of a serious complication, such as acute chest syndrome or stroke. Prompt medical evaluation is crucial to identify and address any underlying complications.
B. While an X-ray may be helpful to rule out other causes of shoulder pain, it is not the most urgent priority in this case. The patient's sudden onset of pain could be a sign of a serious complication that requires immediate attention.
C. While a head-to-toe assessment is important for any patient, it is not the most urgent priority in this case. The patient's new pain could be a sign of a serious complication that requires immediate medical attention.
D. Increasing the opioid dosage may provide temporary relief from the pain, but it does not address the underlying cause of the new pain.
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