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
Apply oxygen 1 L/minute
Give albuterol as ordered
Provide a regular diet tray
Correct Answer : C,D
Based on the client’s current condition and the urgency of the interventions, the nurse should complete the following prescriptions first:
- C) Apply oxygen 1 L/minute: The client’s oxygen saturation level needs to be kept above 94%. Given her difficulty in breathing and the fact that she is pale and sitting upright, it’s crucial to ensure she is receiving enough oxygen.
- D) Give albuterol as ordered: Albuterol is a bronchodilator that can help relieve the client’s asthma symptoms. Since her symptoms did not resolve after taking her usual dose of albuterol, administering another dose as ordered can help improve her breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The patient’s history indicates that she had difficulty breathing during a hike. This event led her to the emergency department. Difficulty breathing during physical activity such as hiking can be a symptom of an asthma exacerbation.
Choice B rationale
While severe allergic reactions can cause difficulty breathing, the patient’s history does not indicate that she experienced an allergic reaction prior to her emergency department visit.
Choice C rationale
Panic attacks can cause symptoms such as rapid heart rate, sweating, and shortness of breath. However, the patient’s history does not indicate that she had a panic attack prior to her emergency department visit.
Choice D rationale
Fainting, or loss of consciousness, can be caused by various conditions, including dehydration, low blood sugar, and heart problems. However, the patient’s history does not indicate that she fainted prior to her emergency department visit.
Correct Answer is B
Explanation
Choice A rationale
Noting the presence of an auscultatory gap, which is a period of abnormal silence in Korotkoff sounds during blood pressure measurement, is important. However, in this case, the silence followed by a Korotkoff sound is a normal finding and does not indicate an auscultatory gap.
Choice B rationale
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. This is a normal finding and indicates that the nurse should continue with the blood pressure assessment.
Choice C rationale
Re-inflating the cuff to a higher number is not necessary in this case as the initial silence followed by a Korotkoff sound is a normal finding.
Choice D rationale
Repositioning the stethoscope over the brachial artery may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.
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