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 ["A","B","C","D","E","F","G"]
Explanation
Correct choices;
Gravida 5, para 5 (G5P5)
This means the client has been pregnant 5 times and has given birth 5 times. Multiparity (having had multiple pregnancies and deliveries) is a risk factor for PPH due to uterine overdistension, which can lead to poor uterine tone and difficulty in contracting effectively after delivery.
Delivery of a 9 lb 1 oz (4.1 kg) baby
Larger babies are associated with an increased risk of PPH. The weight of the baby suggests a potentially larger placental surface area and increased uterine distension during pregnancy, which can contribute to uterine atony post-delivery.
Labor for 25 hours
Prolonged labor can lead to uterine exhaustion, where the uterus may not contract effectively after delivery, predisposing the client to PPH.
Forceps-assisted delivery
Instrumental deliveries, including forceps, can cause trauma to the birth canal, including the cervix, vagina, and perineum, increasing the risk of lacerations and bleeding.
Epidural anesthesia
Epidurals can mask the pain associated with uterine atony, which may delay the diagnosis of PPH. It's important to closely monitor uterine tone and blood loss in clients who have had epidurals.
4th degree laceration
Explanation: A 4th degree laceration involves the perineum and extends through the anal sphincter complex. Such extensive trauma increases the risk of significant bleeding postpartum.
Estimated blood loss of 600 mL
Although this is within the normal range of blood loss immediately after delivery, it still signifies that the client has experienced significant hemorrhage, putting her at higher risk for ongoing bleeding.
Correct Answer is D
Explanation
Rationale
A. Troponin levels are cardiac biomarkers that are elevated in the blood when there is damage to the heart muscle, such as during a myocardial infarction (heart attack). Verifying the schedule for troponin assessments is important to monitor for myocardial damage and to guide treatment decisions.
B. This action is aimed at creating a quiet and calm environment for the client, which can help reduce anxiety and minimize stimuli that might exacerbate symptoms. Creating a conducive environment is beneficial for the client's comfort and well-being but should not delay urgent interventions required for acute symptoms.
C. PVCs are abnormal heartbeats that can occur in individuals with CAD and may indicate increased cardiac irritability or instability. While monitoring PVCs is important for assessing cardiac rhythm and potential complications, it is not the immediate priority over addressing acute symptoms such as shortness of breath, nausea, and chest pressure.
D. Oxygen therapy is essential in the management of a client with suspected ACS to improve oxygenation and reduce cardiac workload. Maintaining oxygen saturation above 93% helps ensure adequate tissue oxygenation, especially during episodes of chest discomfort and potential myocardial ischemia.
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