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 C

Explanation

Rationale

A. This finding suggests that the skin has already broken down, indicating a more advanced stage of pressure injury rather than an early indication. The presence of broken skin typically indicates at least a Stage 2 pressure injury according to the staging system.

B. This description suggests the presence of a deep tissue injury (DTI), which is a late sign of pressure injury.

C. This is indicative of a stage I pressure injury, where the skin is still intact but shows signs of redness that does not blanch with pressure. This stage precedes the actual breakdown of skin seen in more advanced pressure injuries.

D. This finding describes a superficial wound with clear margins, suggesting a Stage 2 pressure injury. It is more advanced than the early signs typically sought for early intervention.

A. Fundus massaged until firm and at umbilicus B. Multiple large clots were expelled C. Straight catheter produced 500 mL clear yellow urine D. Total blood loss of 800 mL E. Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air F. 200 mL blood loss G. Fundus remains firm with slight lochia noted on pad

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

At risk of hypovolemia

D. Total blood loss of 800 mL

A total blood loss of 800 mL indicates significant hemorrhage, which puts the client at risk for hypovolemia (low blood volume). While exact definitions may vary, typically, blood loss exceeding 500 mL postpartum is considered significant and increases the risk of hypovolemia if not managed appropriately.

F. 200 mL blood loss

While 200 mL of blood loss is within the normal range for immediate postpartum period, it still represents a loss of blood that, if ongoing, could potentially lead to hypovolemia if not monitored closely.

Condition has improved

A. Fundus massaged until firm and at umbilicus

Massaging the fundus until it is firm and at the umbilicus helps ensure uterine contraction, which reduces the risk of excessive bleeding and promotes hemostasis. This indicates that uterine tone is adequate, which is a positive sign.

C. Straight catheter produced 500 mL clear yellow urine

The passage of 500 mL of clear yellow urine indicates adequate renal perfusion and hydration status, suggesting that the client's fluid balance is being maintained or improved, which is important in preventing hypovolemia.

E. Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air

Stable vital signs with normal blood pressure, heart rate, and oxygen saturation indicate adequate perfusion and oxygenation. This suggests that the client's condition is stable and not immediately at risk for hypovolemia.

G. Fundus remains firm with slight lochia noted on pad

A firm fundus with slight lochia (postpartum vaginal discharge) indicates ongoing normal involution (shrinking) of the uterus with minimal bleeding. This suggests that the client's uterus is contracting well, which is favorable for preventing hypovolemia.

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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

A client admitted with pneumonia and on bedrest has not had the strength to perform self care. Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Correct Answer is C

Explanation

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether findings suggest that the client's condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"}}

Explanation

D. Total blood loss of 800 mL

F. 200 mL blood loss

A. Fundus massaged until firm and at umbilicus

C. Straight catheter produced 500 mL clear yellow urine

E. Blood pressure of 110/80 mm Hg, heart rate of 66 beats/minute, oxygen saturation at 98% on room air

G. Fundus remains firm with slight lochia noted on pad

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.

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which response by the client indicates understanding?

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

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?