A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse’s priority intervention?

Obtain a sputum sample.

Arrange transport for radiographic imaging.

Move the patient into airborne isolation.

Collect specimens for blood cultures.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Obtaining a sputum sample is important for diagnosing respiratory infections, but it is not the priority intervention in this case. The patient’s symptoms of intermittent fever, night sweats, and a productive cough with small amounts of blood are indicative of a possible airborne disease such as tuberculosis.
Choice B rationale
Arranging transport for radiographic imaging can be helpful in diagnosing the patient’s condition, but it is not the immediate priority. The primary concern should be to prevent the potential spread of an airborne disease.
Choice C rationale
Moving the patient into airborne isolation is the priority intervention. This action is taken to prevent the spread of potential airborne diseases to other patients and healthcare workers.
Choice D rationale
Collecting specimens for blood cultures can help identify the causative organism if the patient has a systemic infection. However, given the patient’s symptoms and the potential for an airborne disease, moving the patient into isolation is the priority.

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Correct Answer is C

Explanation

Choice A rationale
Keeping the head of the bed elevated until the treatment is completed is not typically recommended to reduce the risk of vesicant extravasation during intravenous chemotherapy.
Choice B rationale
Instructing the client to drink plenty of fluids during the treatment does not directly reduce the risk of vesicant extravasation. Hydration can help maintain good vein health, but it does not prevent extravasation.
Choice C rationale
Monitoring the client’s intravenous site hourly during the treatment is a key action to reduce the risk of vesicant extravasation. Regular monitoring allows for early detection of any signs of extravasation, such as swelling or redness at the IV site.
Choice D rationale
Administering an antiemetic before starting the chemotherapy can help manage side effects such as nausea and vomiting, but it does not reduce the risk of vesicant extravasation.

A. Lean beef, salads, and baked potatoes. B. Potatoes, low-fat breads, and applesauce. C. Oatmeal, raisins, and fruit with skin. D. Chicken, rice, and wheat products.

Correct Answer is C

Explanation

Choice A rationale
While lean beef, salads, and baked potatoes can be part of a balanced diet, they are not specifically recommended for patients with a strong family history of colon and rectal cancers.
Choice B rationale
Potatoes and low-fat breads can be part of a balanced diet, but they are not specifically recommended for patients with a strong family history of colon and rectal cancers.
Choice C rationale
Oatmeal, raisins, and fruit with skin are high in fiber, which promotes gut health and is beneficial for colorectal cancer prevention. A nutritious regular diet can improve your gut health, which is a main contributor to colon and rectal health.
Choice D rationale
Chicken, rice, and wheat products can be part of a balanced diet, but they are not specifically recommended for patients with a strong family history of colon and rectal cancers.

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A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse’s priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy?

Correct Answer is C

Explanation

Which group of foods should the nurse recommend for patients with a strong family history of colon and rectal cancers?

Correct Answer is C

Explanation

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

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