Exhibits

After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions.

Which 2 prescriptions should the nurse complete first?

Perform pulmonary function test

Measure vital signs

Provide a regular diet tray

Give albuterol as ordered

Apply oxygen 1 L/minute

Answer and Explanation

Correct Answer : D,E

A.   Perform pulmonary function test
This is important for assessing lung function, but it is not an immediate priority during an acute exacerbation when the patient's oxygen saturation is low and they are experiencing respiratory distress.
Pulmonary function testing can be done once the patient's acute symptoms are stabilized.
B.   Measure vital signs
While vital signs are important for ongoing assessment, the patient's vital signs were already assessed at admission and are being monitored every 4 hours as per orders.
Administering oxygen and albuterol to stabilize the patient's condition takes precedence over routine vital sign checks immediately after the initial assessment.
C.   Provide a regular diet tray
This is a routine aspect of care and does not address the acute respiratory distress or hypoxemia that require immediate attention.
It can be done once the patient's respiratory status has stabilized.
D.   Give albuterol as ordered
The patient is experiencing an asthma exacerbation with wheezing and subcostal retractions. Albuterol is a bronchodilator that helps relieve bronchospasm and improve airflow.
It was ordered for nebulization now and every 4 hours PRN (as needed) for wheezing.
Administering albuterol promptly is crucial to help alleviate respiratory distress and improve lung function.
E.   Apply oxygen 1 L/minute
The patient's oxygen saturation is 91% on room air, which is below the target of greater than 94%. Oxygen therapy is indicated to correct hypoxemia and improve oxygen saturation.
The order specifies to titrate oxygen to keep saturation greater than 94%, starting at 1 L/minute via nasal cannula.

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Correct Answer is ["A","B","C","D","F"]

Explanation

Mild subcostal retractions: Subcostal retractions indicate that the muscles between the ribs are pulling inward during breathing. This is a sign of increased work of breathing and can indicate respiratory distress.

Wheezes noted throughout the lung fields: Wheezing is a high-pitched whistling sound produced during breathing, typically due to narrowed airways. It indicates airway obstruction, common in asthma exacerbations.

Client is pale: Pallor (pale skin) can indicate reduced oxygenation or perfusion to the tissues, which can occur during respiratory distress.

Heart rate of 122 beats/minute: Tachycardia (elevated heart rate) is a compensatory mechanism in response to decreased oxygen levels or increased respiratory effort.

Oxygen saturation 91% on room air: Oxygen saturation below 94% indicates hypoxemia (low blood oxygen levels), which is a critical finding requiring prompt intervention.

A. Monitor blood glucose level. B. Maintain strict intake and output. C. Assess warmth of extremities. D. Keep head of bed raised 45 degrees.

Correct Answer is B

Explanation

Rationale

A. Monitoring blood glucose levels is important, especially in critically ill patients, as hyperglycemia can worsen outcomes in septic shock. However, it is not the most critical intervention in the immediate management of septic shock.

B. Monitoring intake and output (I/O) is essential for assessing fluid balance, which is crucial in managing septic shock. Maintaining a strict I/O helps in determining fluid resuscitation needs and evaluating response to treatment. This intervention is important but may not be the most critical initially.

C. Assessing warmth of extremities is important as it helps in evaluating peripheral perfusion, which can be compromised in septic shock. Cold extremities can indicate poor tissue perfusion and may prompt the need for interventions such as fluid resuscitation.

D. Keeping the head of the bed elevated to 45 degrees is a specific intervention aimed at improving oxygenation and respiratory function, particularly in patients who may be mechanically ventilated or at risk of respiratory compromise. While this is an important intervention, it is not directly related to managing septic shock itself.

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Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","F"]

Explanation

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is B

Explanation

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Exhibits

After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions.

Which 2 prescriptions should the nurse complete first?