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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Free Nursing Study Resources

Correct Answer is []

Explanation

Potential condition: Opioid-induced constipation

Actions to take

Administer a stool softener: Opioids commonly cause constipation by slowing down bowel motility and increasing water absorption in the intestines. A stool softener can help by adding moisture to the stool, making it easier to pass.

Ask the client about their normal bowel routine: Understanding the client's typical bowel habits can provide insights into any deviations caused by the surgery or medication.

Parameters to monitor

Fluid intake: Monitoring the client's fluid intake is crucial as adequate hydration helps maintain bowel function and prevents constipation.

Serum potassium level: Constipation, especially if severe or prolonged, can lead to electrolyte imbalances such as hypokalemia (low potassium levels), which can have serious health implications.

A. Aspirin. B. Nitroglycerin. C. Morphine. D. Heparin.

Correct Answer is B

Explanation

Rationale

A. Aspirin is commonly used in the emergency setting for chest pain suspected to be due to acute coronary syndrome (ACS), which includes conditions like myocardial infarction (heart attack). It works by reducing blood clotting and can help alleviate symptoms in some cases. It is typically safe to administer aspirin

B. Sildenafil can interact with nitrates, such as nitroglycerin, and result in a significant drop in blood pressure. Therefore, the nurse should withhold nitroglycerin to prevent potential adverse effects.

C. Morphine is a potent opioid pain medication used in the emergency department for severe pain relief, including chest pain associated with suspected myocardial infarction. It can help reduce pain and anxiety in acute coronary syndromes. It has no significant interaction with sildenafil.

D. Heparin is an anticoagulant medication used to prevent blood clotting. It is often administered in the hospital setting for various indications, such as deep vein thrombosis, pulmonary embolism, or in some cases of acute coronary syndromes.

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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

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

Correct Answer is []

Explanation

Potential condition: Opioid-induced constipation

Actions to take

Parameters to monitor

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Correct Answer is B

Explanation

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The nurse has reviewed the client's chart. Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that this client is dropdown due to dropdown

Exhibits Which other treatment(s) might be helpful for this client? Select all that apply.

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?