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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 B

Explanation

A. While monitoring erythrocytes, hemoglobin, and hematocrit is important in clients with ESRD due to the risk of anemia associated with kidney dysfunction, it is not the primary focus of monitoring for ESRD.

B. Clients with ESRD often experience electrolyte imbalances, including hyperkalemia (high potassium), hypocalcemia (low calcium), and hyperphosphatemia (high phosphorus). Monitoring these electrolyte levels is crucial to prevent complications such as cardiac arrhythmias, bone
disease, and soft tissue calcifications.

C. While blood pressure, heart rate, and temperature are essential vital signs to monitor in all clients, they are not specific laboratory tests for monitoring ESRD. However, blood pressure monitoring is particularly important in ESRD due to the increased risk of hypertension and its associated complications.

D. Monitoring leukocytes, neutrophils, and thyroxine levels is not typically a primary concern in clients with ESRD. Leukocyte and neutrophil levels may be monitored to assess for signs of infection, but they are not specific to ESRD. Thyroxine levels are typically monitored in clients with thyroid disorders, not ESRD.

A. Encourage mobilization to prevent pulmonary embolism. B. Measure each calf's girth to evaluate edema in the affected leg. C. Observe for bleeding side effects related to heparin therapy. D. Assess blood pressure and heart rate at least every 4 hours.

Correct Answer is C

Explanation

A. Encourage mobilization to prevent pulmonary embolism.
While mobilization can be important in preventing further DVT development, initial bed rest is often recommended to avoid dislodging the clot. Mobilization should be carefully managed based on the provider's recommendations.

B. Measure each calf's girth to evaluate edema in the affected leg.
Measuring calf girth is useful for monitoring the extent of the DVT, but it is not the most critical intervention compared to monitoring for complications of heparin therapy.

C. Observe for bleeding side effects related to heparin therapy.
This is the correct intervention. Heparin is an anticoagulant, and monitoring for signs of bleeding (such as in the gums, urine, stool, and bruising) is crucial to prevent serious complications.

D. Assess blood pressure and heart rate at least every 4 hours.
While important, frequent monitoring of vital signs is secondary to the need to vigilantly observe for bleeding, which is a direct and significant risk of heparin therapy.

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Exhibits

Which 2 orders should the nurse complete first?