The patient is a 49-year-old male who has been experiencing flu-like symptoms, including fever and chest congestion, for 4 days.

He came to the emergency department (ED) last night when his breathing difficulties increased. He has a history of smoking half a pack of cigarettes a day for 20 years.

He has no significant medical or surgical history.

Which two orders should the nurse prioritize?

Chest x-ray

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

Sputum culture

Start oxygen 3 L/minute via nasal cannula

Start a peripheral IV

Acetaminophen 350 mg PO every 6 hours for temperature greater than 38.3° C .

Answer and Explanation

Correct Answer : A,B

Choice A rationale
A chest x-ray is a critical diagnostic tool for a patient presenting with flu-like symptoms, fever, chest congestion, and increased breathing difficulties. It can help identify conditions such as pneumonia or other lung diseases, which could be causing the patient’s symptoms.
Choice B rationale
While hydration is important, running a 0.9% sodium chloride IV infusion at 150 mL/hour is not the most immediate need for this patient. The patient’s symptoms are primarily respiratory, and there is no indication of dehydration.
Choice C rationale
A sputum culture could be useful for diagnosing bacterial infections of the respiratory tract. However, it is not the most immediate need for this patient, as the results of a culture test can take time to come back.
Choice D rationale
This is the correct answer. Given the patient’s increased breathing difficulties, starting oxygen therapy can help improve the patient’s oxygen levels and ease their breathing.
Choice E rationale

Starting a peripheral IV might be necessary for administering medications or fluids, but it is not the most immediate need in this scenario.
Choice F rationale
While controlling the patient’s fever is important, it is not as immediate a need as performing a chest x-ray and starting oxygen therapy.

Nursing Test Bank

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Correct Answer is A

Explanation

Choice A rationale

Monitoring the patient’s cardiac activity via telemetry is the most important intervention for a patient with acute renal failure (ARF), uncontrolled type 1 diabetes mellitus, and hyperkalemia who is receiving an IV dose of regular insulin. Hyperkalemia can cause cardiac arrhythmias and other cardiac complications. Therefore, continuous cardiac monitoring is crucial to detect any changes in heart rhythm or rate that could indicate worsening hyperkalemia.
Choice B rationale
While assessing glucose via fingerstick every 4 to 6 hours is important for a patient with uncontrolled type 1 diabetes mellitus, it is not the most important intervention in this scenario. The patient’s hyperkalemia and ARF pose more immediate risks.
Choice C rationale
Evaluating hourly urine output for return of normal renal function is an important part of monitoring a patient with ARF34. However, in the context of hyperkalemia and the administration of insulin, cardiac monitoring is more critical.
Choice D rationale
Maintaining venous access with an infusion of normal saline is a standard nursing intervention for most hospitalized patients, but it is not the most important intervention in this scenario.

A. Test the fluid on the dressing for glucose. B. Change the dressing using a compression bandage. C. Mark the drainage area with a pen and continue to monitor. D. Document the findings in the electronic medical record.

Correct Answer is A

Explanation

Choice A rationale
Testing the fluid on the dressing for glucose is the immediate course of action when a nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. Clear fluid could be cerebrospinal fluid (CSF), which contains glucose. If the fluid is positive for glucose, it could indicate a CSF leak, which requires immediate medical attention.
Choice B rationale
Changing the dressing using a compression bandage is not the immediate course of action. The source of the fluid needs to be identified first.
Choice C rationale
Marking the drainage area with a pen and continuing to monitor is not the immediate course of action. The source of the fluid needs to be identified first.
Choice D rationale
Documenting the findings in the electronic medical record is important, but it is not the immediate course of action. The source of the fluid needs to be identified first.

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Naxlex Comprehensive Predictor Exams

A patient with acute renal failure (ARF) is admitted due to uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. What is the most important intervention for the nurse to include in this patient’s plan of care?

Correct Answer is A

Explanation

A nurse notices clear fluid on the surgical dressing of a patient who has just returned from lumbar spinal surgery. What should be the nurse’s immediate course of action?

Correct Answer is A

Explanation

A client with a venous ulcer, which has not responded to intravenous vancomycin treatment and is discharging pus, has been admitted with a potential infection of Vancomycin-Resistant Enterococci (VRE). Which nursing interventions should be included in the care plan? Select all that apply.

The nurse is preparing a 50 mL dose of 50% dextrose IV for a patient with insulin shock. What is the appropriate method for administering the medication?

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

A nurse is preparing a 50 mL dose of 50% dextrose IV for a patient experiencing insulin shock. What is the best method for administering the medication?

Which assessment finding is most crucial when planning to provide a complete bed bath to a bedfast client?