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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. This comment suggests that the client is aware of the correct technique (inhaling and holding breath) but finds it difficult to execute properly. It indicates a partial understanding of the inhaler technique but potential difficulty in coordination.
B. This comment indicates a misunderstanding of the purpose of a rescue inhaler. Rescue inhalers are intended to be used promptly at the onset of symptoms to relieve acute shortness of breath. Delaying use until symptoms are severe may result in inadequate relief and worsening of respiratory distress.
C. This comment suggests that the client may be swallowing the medication instead of inhaling it into the lungs. Inhalers are meant to deliver medication directly into the lungs through inhalation, not swallowing. Swallowing the medication can lead to gastrointestinal side effects like nausea.
D. Shaking the inhaler before use is a correct step to ensure proper dispersion of the medication. This comment indicates the client understands and follows this part of the inhaler technique correctly.
Correct Answer is ["A","B","C"]
Explanation
Blood pressure 90/62 mm Hg
A blood pressure of 90/62 mm Hg indicates hypotension, which could be indicative of hypovolemia (low blood volume) due to postpartum hemorrhage. Hypotension needs immediate evaluation and intervention to prevent further complications.
Oxygen saturation of 89%
An oxygen saturation of 89% on room air is below the normal range (typically 95-100%). This suggests the client is not adequately oxygenating, which could be due to various reasons such as respiratory compromise or inadequate ventilation. Immediate follow-up is necessary to determine the cause and initiate appropriate interventions.
Fundus rotated to the right
The displacement of the fundus could be due to the presence of a distended bladder pushing the uterus to one side which may increase uterine atony.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.