Find patient data about a client below.

After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?

Provide a regular diet tray

Measure vital signs

Apply oxygen 1 L/min

Give Albuterol as ordered

Perform pulmonary function test

Answer and Explanation

Correct Answer : B,D

A)   Incorrect - Providing a regular diet tray is important for the client's nutritional needs, but it is not as urgent as assessing vital signs or administering Albuterol in response to the client's acute symptoms.
B)   Correct- This action is a priority after any assessment or intervention. Vital signs provide important information about the client's overall condition, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
C)   Incorrect - Applying oxygen is important, but its priority depends on the client's vital signs and oxygen saturation, which should be assessed first.
D)   Correct- Administering Albuterol as ordered is crucial for addressing the client's acute breathing difficulty. Albuterol is a bronchodilator that helps alleviate asthma symptoms, and timely administration is essential.
E)   Incorrect - Performing a pulmonary function test is valuable for assessing lung function, but it's not an immediate concern compared to addressing the client's breathing difficulty.

Nursing Test Bank

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Correct Answer is C

Explanation

The correct answer is c. Raise the side rails and notify the family to come and stay until the client is reoriented and cooperative. This intervention ensures the client’s safety and provides familiar support, which can help reorient and calm the client.

Choice A reason: Administering a prescribed narcotic antagonist assumes the agitation is due to narcotic accumulation without evidence. This could lead to unnecessary medication administration.

Choice B reason: Requesting restraints should be a last resort due to the risks of injury and increased agitation. Restraints can also lead to further complications.

Choice C reason: Raising the side rails and involving the family provides immediate safety and emotional support, which can help reorient the client. Familiar faces can be very calming and reassuring.

Choice D reason: Instructing a UAP to check on the client every 15 minutes lacks the immediate family support that can help reorient the client. Continuous monitoring is important, but family involvement is more effective.

A. Place an indwelling urinary catheter and measure strict intake and output. B. Maintain elevated positioning of the dependent joints on affected side. C. Raise the head of the bed to 30 degrees keep head and neck in neutral alignment. D. Determine when symptoms began and if improved or worsened since onset.

Correct Answer is D

Explanation

A) Incorrect- While monitoring urinary output is important for overall assessment, it is not the most critical intervention in this situation of suspected stroke. The client's neurological symptoms take precedence.
B) Incorrect- Positioning might be relevant to preventing complications, but it is not the highest priority intervention in this situation. The focus should be on assessing the client's neurological status and determining appropriate intervention.
C) Incorrect- Although head positioning is relevant for intracranial pressure management, it is not the immediate priority. The nurse should first assess the time of symptom onset and determine if the client is experiencing an acute stroke.
D) Correct- The client's symptoms, including sudden severe headache, facial numbness, facial droop, and weakness on one side, are suggestive of a stroke. The nurse should prioritize assessing the time of symptom onset, as time is a crucial factor in determining the appropriate intervention. Rapid intervention can improve outcomes in stroke cases, especially when considering interventions like thrombolytic therapy. The other options are not as directly relevant to the immediate management of a suspected stroke.

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Find patient data about a client below. After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An elderly client is 12-hours postoperative for a hernia repair and suddenly becomes agitated, staggers out into the corridor, and demands to be set free. After assisting the client back to bed and administering pain medication, which intervention is best for the practical nurse (PN) to implement?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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Find patient data about a client below.

After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?