Exhibits
Highlight the 3 orders that should be completed first.
Orders
- Administer oxygen 5 L/minute via simple face mask
- Vital signs ever 1 hour
- X-ray of the right arm and cervical spin
- Place 2 large bore peripheral IV's
- Computed tomography scan of the brain
- Give 1 Liter bolus of 0.9% sodium chloride solution IV once
- Bacitracin applied topically to lacerations every 12 hours
Administer oxygen 5 L/minute via simple face mask
Bacitracin applied topically to lacerations every 12 hours
Place 2 large bore peripheral IV's
X-ray of the right arm and cervical spin
Computed tomography scan of the brain
Vital signs ever 1 hour
Give 1 Liter bolus of 0.9% sodium chloride solution IV once
The Correct Answer is ["A","C","G"]
A. Administer oxygen 5 L/minute via simple face mask: Oxygen administration is a priority intervention to improve oxygenation and address the client's low oxygen saturation of 82%.
Hypoxemia can lead to tissue hypoxia and further compromise the client's condition. Therefore, administering oxygen should be the first action taken to ensure an adequate oxygen supply to vital organs.
B. Bacitracin applied topically to lacerations every 12 hours: While wound care is important, administering oxygen and establishing IV access take precedence over topical
treatment. Oxygenation and fluid resuscitation are critical in the immediate management of a trauma patient to ensure adequate tissue perfusion and oxygen delivery.
C. Place 2 large bore peripheral IV's: Establishing IV access is essential for administering medications and fluids rapidly. This is particularly important in this scenario where the client may require immediate fluid resuscitation due to hypotension (blood pressure of 83/41 mm Hg).
Large bore IV access allows for rapid infusion of fluids and medications to stabilize the client's hemodynamic status.
D. X-ray of the right arm and cervical spine: While diagnostic imaging is important for assessing injuries, it is not as urgent as administering oxygen and establishing IV access. Oxygenation and fluid resuscitation are higher priorities to stabilize the client's condition before proceeding with diagnostic tests.
E. Computed tomography scan of the brain: While a CT scan of the brain is essential for assessing potential head injuries, the immediate focus should be on stabilizing the client's oxygenation and hemodynamic status. Administering oxygen and fluids take precedence over diagnostic imaging to address the client's hypoxemia and hypotension.
F. Vital signs every 1 hour: Monitoring vital signs is important for ongoing assessment, but it is not as urgent as administering oxygen and fluids. Vital signs should be monitored closely, but immediate interventions to address hypoxemia and hypovolemia are critical to stabilize the client's condition.
G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once: The client's hypotension (blood pressure of 83/41 mm Hg) indicates hypovolemia and the need for fluid resuscitation. Administering a bolus of intravenous fluids (1 Liter bolus of 0.9% sodium chloride solution) is essential to address hypovolemia and improve perfusion to vital organs. This intervention helps stabilize the client's blood pressure and prevent further deterioration of her condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While a history of urinary tract infections is important to know for overall assessment and planning of care, it may not directly affect the decision to insert a urinary catheter unless there are specific concerns related to infection prevention.
B. The client's ability to increase fluid intake may be relevant to their overall hydration status and urinary function but is not directly related to the insertion of an indwelling urinary catheter.
C. This is the most important information to obtain because the nurse needs to ensure that the client does not have any allergies to antiseptic solutions that may be used during the catheter insertion procedure to prevent infection.
D. While the color, clarity, and odor of urine are important indicators of urinary health, they are not the most critical information to obtain prior to catheter insertion. However, assessing urine characteristics is important for ongoing monitoring of urinary function and potential
complications post-insertion.
Correct Answer is B
Explanation
A. These laboratory values will provide data to anticipate delays in growth and development.
While abnormal results from these tests could indicate potential developmental issues, the primary purpose of the screening is not to predict delays in growth and development but to identify metabolic deficiencies.
B. This is a routine blood test required by law to screen for metabolic deficiencies.
This is the correct answer. Neonatal screening, including tests for T4 and TSH, is a standard practice mandated by law in many regions to identify metabolic deficiencies such as congenital hypothyroidism early on, ensuring prompt treatment to prevent serious health issues.
C. Dosages for thyroid replacement therapy will be determined by this test.
This explanation might be applicable if a deficiency is detected, but it is not the primary reason for conducting the initial screening. The primary purpose is to identify whether there is a need for treatment.
D. Although untreated metabolic deficiencies like congenital hypothyroidism can lead to intellectual disabilities, the primary goal of the screening is to detect and treat these deficiencies before they can cause such problems.
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