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.

Nursing Test Bank

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Correct Answer is D

Explanation

Rationale

A. Ear pain is not typically a common symptom of mononucleosis. Fever, however, is commonly seen in mononucleosis due to the body's immune response to the viral infection.

B. In mononucleosis, there is often an increase in white blood cells (specifically lymphocytes) and an elevated sedimentation rate (ESR). These changes reflect the body's immune response to the Epstein- Barr virus infection.

C. Increased blood urea nitrogen (BUN) and serum creatinine levels are not typically associated with mononucleosis. These markers are more indicative of kidney function and are not directly affected by the viral infection causing mononucleosis.

D. A positive test for Epstein-Barr virus (EBV) antibodies is diagnostic for mononucleosis. Malaise, which is a general feeling of discomfort or illness, is a hallmark symptom of mononucleosis along with other systemic symptoms like fatigue, sore throat, swollen lymph nodes, and sometimes a rash.

A. A bedside commode is positioned near the bed. B. The client is lying in a supine position in bed. C. A low sodium diet tray was brought to the room. D. A full pitcher of water is on the bedside table. E. A saline lock is present in the right forearm.

Correct Answer is ["B","D"]

Explanation

Rationale

A. This is generally a good practice for clients who may have difficulty ambulating to the bathroom due to their condition. It promotes safety and reduces the risk of falls, especially during episodes of dyspnea.

B. A supine position can increase venous return to the heart and exacerbate symptoms of heart failure by increasing preload. This can lead to increased pulmonary congestion and respiratory distress. Therefore, this observation requires immediate intervention.

C. Providing a low sodium diet aligns with managing heart failure by reducing fluid retention and workload on the heart. This observation does not require immediate intervention unless there are specific dietary restrictions or concerns.

D. In heart failure, fluid restriction is often necessary to prevent fluid overload and exacerbation of symptoms. Having a full pitcher of water accessible to the client could lead to excessive fluid intake, which is concerning and requires immediate intervention.

E. A saline lock allows access for intravenous medications or fluids if needed. Its presence does not necessarily indicate a need for immediate intervention unless it is not functioning properly or if there are signs of infection or infiltration.

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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

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

Correct Answer is D

Explanation

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? Select all that apply.

Correct Answer is ["B","D"]

Explanation

An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? 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?