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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.

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Correct Answer is A

Explanation

A. Focusing on small achievable tasks helps to build a sense of accomplishment and reduce anxiety by breaking down overwhelming problems into manageable steps.

B. Analyzing past hurts may be useful in therapy, but for immediate coping, focusing on small tasks is more practical.

C. Relaxing and reducing effort might lead to avoidance rather than addressing anxiety.

D. Ventilating emotions is important but focusing on small tasks is more directly actionable for coping with anxiety and improving daily functioning.

A. Impaired comfort. B. Impaired skin integrity. C. Risk for infection related to traumatic fracture. D. Risk for peripheral neurovascular dysfunction.

Correct Answer is D

Explanation

A. While impaired comfort is a concern, the priority is to address potential neurovascular compromise.

B. Impaired skin integrity is a concern but not the most immediate issue given the symptoms described.

C. Risk for infection is important but secondary to the acute concern of neurovascular function.

D. Risk for peripheral neurovascular dysfunction is the highest priority as it indicates potential compartment syndrome or other serious complications requiring urgent intervention.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Patient Data

Exhibits

Which 2 prescriptions should the nurse complete first?