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Patient Data

Exhibits

Which 2 prescriptions should the nurse complete first?

Acetaminophen 650 mg PO every 6 hours for temperature greater than 101.0° F (38.3° C)

Start a peripheral IV

Chest x-ray

NPO

Start oxygen 3 L/minute via nasal cannula

Sputum culture

Place the client on a cardiorespiratory monitor

Run 0.9% sodium chloride IV infusion at 150 mL/hour

Answer and Explanation

Correct Answer : B,E

A. Acetaminophen 650 mg PO every 6 hours for temperature greater than 101.0° F (38.3° C): While managing fever is important, it is not as immediate a priority as ensuring the client's breathing and hydration.

B. Start a peripheral IV: Establishing a peripheral IV line is crucial for administering medications and fluids. This is essential for the client's hydration and potential intravenous medication needs.

C. Chest x-ray: Although a chest x-ray is important for diagnosing the cause of the symptoms, it can be done after the client’s immediate needs for oxygen and IV access are addressed.

D. NPO: Keeping the client NPO is necessary, but it doesn't require immediate action compared to oxygenation and IV access.

E. Start oxygen 3 L/minute via nasal cannula: The client is experiencing difficulty breathing, so providing supplemental oxygen is a priority to ensure adequate oxygenation and alleviate respiratory distress.

F. Sputum culture: Obtaining a sputum culture is important for diagnosis, but it can wait until after the client is stabilized with oxygen and IV access.

G. Place the client on a cardiorespiratory monitor: Monitoring the client's cardiac and respiratory status is important, but ensuring oxygenation and IV access takes precedence.

H. Run 0.9% sodium chloride IV infusion at 150 mL/hour: While starting the IV infusion is important, it follows the establishment of the IV line and oxygen administration.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Inserting a urinary catheter is a skill that typically requires a licensed nurse's expertise.

B. Titrating oxygen requires assessment and adjustment based on clinical findings, which is outside the UAP’s scope of practice.

C. Procuring platelet products from the blood bank is a non-clinical task that can be safely assigned to a UAP.

D. Monitoring an IV infusion rate involves clinical judgment and is typically performed by a licensed nurse.

A. Determine if the client has recently experienced a fall. B. Instruct the adult child to check the client's temperature. C. Ask if the client is experiencing any pain with urination. D. Encourage increased intake of high protein foods. E. Review the client's current food and medication allergies.

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

Explanation

A. Falls can lead to head injuries or subdural hematomas, which can cause confusion in older adults. It is important to assess for recent trauma as a possible cause of the confusion.

B. An elevated temperature can indicate an infection, such as a urinary tract infection (UTI) or pneumonia, which are common causes of acute confusion in older adults.

C. Pain with urination is a symptom of a UTI, which can lead to confusion, especially in elderly patients with Parkinson's disease.

D. While maintaining adequate nutrition is important, increasing protein intake does not directly address the sudden onset of confusion.

E. New medications or allergic reactions can lead to confusion. A medication interaction or an allergic reaction to a new food could be a contributing factor.

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Patient Data Exhibits Which 2 prescriptions should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

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

Explanation

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Patient Data

Exhibits

Which 2 prescriptions should the nurse complete first?