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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

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}

Explanation

A. anaphylaxis

The correct answer is A. Anaphylaxis is a severe, life-threatening allergic reaction that can occur in response to medication administration. The client's symptoms of dizziness, headache, burning feeling on extremities, and redness on face and extremities, along with the sudden onset of symptoms after starting vancomycin infusion, are indicative of a possible anaphylactic reaction.

B. arrhythmias

The correct answer is B. Arrhythmias refer to abnormal heart rhythms, which can be

triggered by various factors including medication reactions. Given the client's history of symptomatic bradycardia and the sudden onset of symptoms after starting vancomycin infusion, arrhythmias such as bradycardia or other rhythm disturbances are a concern.

C. Cardiac arrest

The correct answer is C. Cardiac arrest is the cessation of normal heart function, which can be precipitated by severe arrhythmias or anaphylaxis. The client's symptoms, along with the drop in blood pressure, indicate a potential risk of progressing to cardiac arrest if not promptly treated.

D. Necrosis

Necrosis, or tissue death, is not typically associated with the symptoms described in the scenario. While vancomycin infusion can potentially cause tissue irritation or damage at the
injection site, the symptoms described suggest a systemic reaction rather than localized tissue necrosis.

E. Renal failure

Renal failure is not directly indicated by the symptoms described in the scenario. While vancomycin can be nephrotoxic in some cases, the symptoms of dizziness, headache, and redness are more suggestive of an allergic or cardiovascular reaction.

F. Peripheral edema

Peripheral edema, or swelling in the extremities, is not indicated by the symptoms described in the scenario. The client's symptoms, such as dizziness, headache, and redness, are more
indicative of a systemic reaction rather than localized swelling.

A. Involve your mother in the decision making process. B. Moving your mother into a care facility will show her that you do not love her C. It is okay not to love or like your mother when you are caring for her. D. You made a promise to your mother that you need to keep. E. Take time for yourself and the other relationships that you care about. F. Saying "no" to things involving the care of your mother is a selfish action. G. Helping your mother should be easier than raising a child.

Correct Answer is ["A","C","E"]

Explanation

A. Involve your mother in the decision-making process promotes autonomy and shared responsibility, helping the caregiver feel less burdened and improving the client’s satisfaction and participation in care.

B. Moving your mother into a care facility will show her that you do not love her increases caregiver guilt and stress rather than helping them cope.

C.Normalizing mixed emotions acknowledges that caregivers may feel frustration or emotional fatigue without judgment, helping reduce guilt and emotional distress.

D. You made a promise to your mother that you need to keep reinforces obligation and may increase feelings of guilt and pressure.

E. Take time for yourself and the other relationships that you care about is essential for preventing burnout, maintaining personal time and social connections, and supporting the caregiver’s ability to provide care effectively.

F.Labeling refusal as selfish increases guilt and pressure, which worsens caregiver strain and is not supportive communication.

G. Helping your mother should be easier than raising a child can increase stress and feelings of inadequacy by creating unrealistic expectations about caregiving.

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Exhibits

The nurse is implementing solutions to provide care.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of dropdown
, dropdown
 and dropdown

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Exhibits Which 2 orders should the nurse complete first?

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence. The client is at immediate risk for developing dropdown-1,dropdown-2 and dropdown-3

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}

Explanation

Correct Answer is ["A","C","E"]

Explanation

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Exhibits Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

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Exhibits

Which 2 orders should the nurse complete first?