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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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Free Nursing Study Resources

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

Explanation

A. Peripheral pallor is not a typical pain indicator.

B. Restlessness can be a sign of discomfort or pain in infants.

C. Increased respiratory rate can indicate pain or distress.

D. Increased temperature is more indicative of infection than pain.

E. Clenched fists can be a sign of pain or discomfort in infants.

F. Increased pulse rate is a common physiological response to pain.

A. Use standard precautions and wear a mask. B. Institute contact precautions for staff and visitors. C. Explain the purpose of a low bacteria diet. D. Monitor the client's white blood cell count. E. Send wound drainage for culture and sensitivity.

Correct Answer is ["B","D","E"]

Explanation

A. Standard precautions are important, but VRE requires contact precautions due to its highly transmissible nature. A mask is not specifically required unless there are respiratory symptoms.

B. Contact precautions are essential for preventing the spread of VRE and should be instituted for staff and visitors.

C. A low bacteria diet is not necessary for VRE infections; it is more relevant for immunocompromised patients.

D. Monitoring the white blood cell count helps assess the infection's progression and the body's response.

E. Sending wound drainage for culture and sensitivity is crucial for identifying the specific pathogen and determining appropriate antibiotic treatment.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a 3-month-old client who had a pyloromyotomy yesterday. This child should be medicated for pain based on which finding(s)? Select all that apply.

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

Explanation

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

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The nurse is assessing a client who recently had an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing. Based on these findings, this client is at greatest risk for which pathophysiological condition?

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The nurse is providing dietary education to a client in end stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the client's daily diet?

Patient Data

Exhibits

Which 2 prescriptions should the nurse complete first?