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A patient's data shows the following: Oxygen saturation is 94% on room air, pain is 4 on a scale of 0 to 10, temperature is 99.6°F (37.6°C) orally, and heart rate is 95 beats/minute.
Which physician orders would the nurse anticipate being prescribed after reporting these findings? Select all that apply.

Place client on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.

Stat ventilation/perfusion (V/Q) of chest.

Stat 2 views chest x-ray.

Stat Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.

Send sputum for culture & sensitivity.

Answer and Explanation

Correct Answer : A,C,D

The correct answer is choice A, C, and D.

Choice A rationale:

The patient’s oxygen saturation is at 94%, which is just below the normal range of 95-100% for healthy adults breathing room air. Administering oxygen 2 to 4 liters to maintain oxygen saturation at or above 95% is a standard intervention to ensure adequate oxygenation.

Choice B rationale:

A stat ventilation/perfusion (V/Q) scan is typically ordered for suspected pulmonary embolism, which is not indicated by the patient’s current data. The patient’s symptoms do not specifically suggest a V/Q mismatch that would necessitate this diagnostic test.

Choice C rationale:

A chest x-ray is a common diagnostic tool for evaluating the lungs and heart, especially when a patient presents with symptoms that may indicate respiratory or cardiac issues. Given the patient’s temperature and heart rate, which are slightly elevated, a chest x-ray can help identify any potential underlying conditions.

Choice D rationale:

Ordering a CBC, BMP, and blood cultures can help identify the cause of the patient’s fever and tachycardia. These tests provide valuable information about the patient’s immune response, electrolyte balance, kidney function, and whether there is a bacterial infection.

Choice E rationale:

While sending sputum for culture and sensitivity could be helpful if a respiratory infection is suspected, the patient’s data does not strongly indicate a respiratory infection as the primary issue. Therefore, this test may not be the most immediate need.

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Correct Answer is B

Explanation

Choice A rationale:

Leaving the dressing off would expose the wound to air and potential contamination, which could delay healing and increase the risk of infection.

While consulting with the healthcare provider is always an option, it's not necessary in this case as the nurse has the knowledge and skills to select an appropriate dressing.

Additionally, leaving the wound uncovered could cause pain and discomfort to the patient, as well as potentially disrupt the delicate granulation tissue that has already formed.

Choice C rationale:

Increasing the frequency of dressing changes could disrupt the healing process and irritate the wound bed.

It's generally recommended to change dressings only as often as necessary to keep the wound clean and moist. Excessive dressing changes can also be costly and time-consuming for both the patient and the healthcare provider. Choice D rationale:

Transparent dressings are not ideal for stage 3 pressure injuries with significant granulation tissue. These dressings are more suitable for wounds with minimal exudate and that are not actively healing. Transparent dressings can also adhere to the wound bed, causing pain and trauma upon removal.

Choice B rationale:

Hydrocolloidal gel dressings are a good choice for stage 3 pressure injuries with granulation tissue because they: Provide a moist wound environment, which promotes healing.

Absorb exudate, which helps to prevent maceration of the surrounding skin. Form a protective barrier over the wound, which helps to prevent infection.

Are comfortable for the patient and can be left in place for several days.

A. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. B. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). C. Report the COVID-19 result to the local health department according to Center for Disease Control (CDC) guidelines. D. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient.

Correct Answer is B

Explanation

Choice A rationale:

While teaching the client about infection prevention measures is important, it is not the most immediate priority in this situation. The client is already potentially contagious, and these measures may not be sufficient to prevent transmission if the client is not properly isolated.

It's crucial to remember that the client may be experiencing cognitive impairment due to illness, making it harder to fully comprehend and adhere to instructions.

Additionally, some clients may not have access to or be able to afford masks and hand sanitizer, potentially hindering compliance with these measures.

Choice B rationale:

Isolating the client is the most critical action to prevent the spread of COVID-19 to others. This includes separating the client from other patients, family members, and healthcare workers who are not wearing proper PPE.

PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the client, minimizing the risk of transmission via direct contact or droplets.

Proper isolation techniques include placing the client in a designated negative-pressure isolation room, if available, or designating a separate area within a multi-bed room.

It's essential to restrict the client's movement within the healthcare facility and limit visitors to essential personnel only.

Choice C rationale:

Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus; however, it is not the most immediate priority in this situation.

The priority is to prevent further transmission by isolating the client.

Choice D rationale:

Counseling family members to monitor for symptoms is important, but it is not the most immediate priority in this situation. The priority is to prevent transmission by isolating the client.

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Naxlex Comprehensive Predictor Exams

The nurse is performing a routine dressing change for a patient with a stage 3 pressure injury that is red with significant granulation.The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is B

Explanation

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

The patient’s vital signs are as follows: Temperature 97.5 F (36.4 C), Heart rate 104 beats/minute, Respirations 29 breaths/minute, Blood pressure 119/82 mm Hg, Oxygen saturation 89%. Oxygen mask applied.What should the nurse do next?

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