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 .
Correct Answer : A,D
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Periodic sighing and shaking of the head can be signs of agitation and distress. These behaviors may indicate that the client is struggling to manage their emotions and may need additional support or intervention.
Choice B rationale
A decreased activity level and change in affect can be signs of many different mental health conditions, but they are not typically associated with agitation. Therefore, while these behaviors should be monitored, they are not the priority in this situation.
Choice C rationale
Repeated requests for attention from the nurse can be a sign of agitation. This behavior may indicate that the client is feeling distressed and is seeking help in managing their emotions.
Choice D rationale
Argumentativeness and use of profanity are clear signs of agitation. These behaviors can escalate quickly and may pose a risk to the safety of the client and others on the unit.
Therefore, these behaviors should be prioritized for monitoring.
Correct Answer is D
Explanation
Choice A rationale
While pallor can indicate various health issues such as anemia or low blood flow, it is not the most crucial finding when planning to provide a complete bed bath to a bedfast client.
Choice B rationale
Right-sided paralysis could affect the client’s ability to assist with the bath and could require special care or positioning. However, it is not the most crucial finding in this context.
Choice C rationale
2+ pitting edema of the feet could indicate fluid overload or poor circulation, but it is not the most crucial finding when planning to provide a complete bed bath.
Choice D rationale
This is the correct answer. Orthopnea, or difficulty breathing while lying flat, is the most crucial finding in this context. If a client has orthopnea, they may need to be positioned in a way that allows them to breathe comfortably during the bath.
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