Exhibits
Which 2 orders should the nurse complete first?
Acetaminophen 350 mg PO every 6 hours for temperature greater than 101° F (38.3°C)
Place the client on a cardiorespiratory monitor
Start oxygen 3 L/minute via nasal cannula
Chest x ray
Run 0.99% sodium chloride IV infusion at 150 ml/hour
Start a peripheral IV
Sputum culture
Correct Answer : B,C
A. Acetaminophen 350 mg PO every 6 hours for temperature greater than 101°F (38.3°C): While controlling fever is important, it is not as urgent as ensuring adequate oxygenation and
monitoring of vital signs. Fever can be managed once the client's respiratory status is stabilized.
B. Place the client on a cardiorespiratory monitor
The correct answer is B. Placing the client on a cardiorespiratory monitor is crucial to continuously monitor vital signs, including heart rate, respiratory rate, oxygen saturation, and cardiac rhythm. Given the client's reported difficulty breathing, this order takes priority to assess the severity of respiratory distress and ensure timely intervention if needed.
C. Start oxygen 3 L/minute via nasal cannula
The correct answer is C. Initiating oxygen therapy is essential for improving oxygenation and respiratory function, especially in a patient with reported difficulty breathing. Administering oxygen can help alleviate hypoxemia and reduce the workload on the respiratory system. This intervention takes precedence in addressing the client's acute respiratory symptoms.
D. Chest x-ray: A chest x-ray is important for further evaluation of the client's respiratory status, but it is not as immediate as placing the client on a cardiorespiratory monitor and initiating oxygen therapy.
E. Run 0.9% sodium chloride IV infusion at 150 mL/hour: Initiating IV fluids is important, but it is not as urgent as addressing the client's respiratory distress and oxygenation needs.
F. Start a peripheral IV: Starting a peripheral IV is necessary for administering medications and fluids, but it can be done after placing the client on a monitor and starting oxygen therapy.
G. Sputum culture: While obtaining a sputum culture is important for identifying the causative organism of the respiratory infection, it is not as urgent as addressing the client's immediate respiratory distress.
H. NPO: NPO status may be necessary for certain diagnostic tests or procedures, but it does not take priority over addressing the client's respiratory distress and oxygenation needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Vegetarian lasagna with cheese and spinach, tossed green salad with ranch dressing, and fresh fruit. This meal option contains carbohydrates from the lasagna, salad dressing, and fruit, which can raise blood glucose levels.
B. Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake.
This meal option contains carbohydrates from the bun and angel food cake, which can raise blood glucose levels.
C. Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie. This meal option contains significant amounts of carbohydrates from mashed potatoes and apple pie, which can raise blood glucose levels.
D. Grilled fish with whole-grain brown rice, steamed broccoli, and pear poached in red wine.
This meal option is lower in carbohydrates and contains healthier choices for a client with diabetes, helping to control blood glucose levels more effectively.
Correct Answer is C
Explanation
A. Wearing an N95 respiratory mask is not typically required for routine care of a toddler with respiratory syncytial virus unless performing procedures that generate aerosols.
B. Negative pressure rooms are generally reserved for patients with airborne infections like tuberculosis; respiratory syncytial virus does not typically require isolation in a negative pressure room.
C. Using a designated stethoscope helps prevent the spread of infection to other patients by avoiding cross-contamination.
D. Removing the disposable gown after leaving the toddler's room is appropriate for maintaining infection control but is not specific to caring for a toddler with respiratory syncytial virus.
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