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 C
Explanation
A. 2+ pitting edema of the feet. While edema requires monitoring and may necessitate some adjustments in care, it does not directly impact the ability to provide a bed bath.
B. Pallor. Pallor indicates potential anemia or poor circulation but does not directly impact the provision of a bed bath.
C. Orthopnea. Orthopnea, difficulty breathing when lying flat, is critical to consider when planning a bed bath. The client may need to be positioned with the head elevated to facilitate breathing and ensure comfort during the bath.
D. Right-sided paralysis. Paralysis requires careful handling to prevent injury, but it is not as
immediately critical to the bathing process as orthopnea, which directly affects the client's ability to breathe comfortably.
Correct Answer is ["B","C","D"]
Explanation
A. Instruct client and family to reconsider end of life choices.
This is not an appropriate intervention. In hospice care, the focus is on providing comfort and supporting the client’s and family’s current end-of-life choices rather than challenging them.
B. Encourage family to visit frequently.
Encouraging family visits can provide emotional support and comfort to the client, helping them cope with feelings related to death and dying.
C. Teach client how to use guided imagery.
Guided imagery can be a helpful technique for managing anxiety and emotional distress, offering the client a method to find peace and comfort.
D. Encourage family to bring the client old photographs.
Old photographs can help evoke positive memories and provide comfort, aiding the client in coping with feelings of death and dying.
E. Record the client's desire to live.
Recording the client's desires is important for documenting their wishes, but it is not an intervention that directly aids in coping with feelings related to death and dying.
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