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,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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
A productive cough is not a specific indicator of hypoxia. It could be a symptom of many conditions, including a common cold, flu, or other respiratory tract infections.
Choice B rationale
A respiratory rate of 28 breaths/minute is higher than the normal range (12-20 breaths/minute for adults), indicating that the patient may be trying to increase oxygen intake and eliminate carbon dioxide due to hypoxia.
Choice C rationale
An oxygen saturation of 90% on room air is lower than the normal range (95%-100%). This indicates that the patient’s blood is not carrying as much oxygen as it should, which is a sign of hypoxia.
Choice D rationale
A heart rate of 101 beats/minute is higher than the normal range (60-100 beats/minute for adults). This could be a response to hypoxia as the body tries to deliver more oxygen to the tissues.
Choice E rationale
A capillary refill of 4 seconds is slightly longer than the normal range (less than 2 seconds). While this could indicate poor peripheral circulation, it is not a specific or direct indicator of hypoxia.
Choice F rationale
A blood pressure of 145/89 mm Hg is higher than the normal range (less than 120/80 mm Hg). While hypertension could be related to many factors, it is not a specific indicator of hypoxia.
Correct Answer is C
Explanation
Choice A rationale
While the sensitivity of genetic markers can influence the choice of treatment, it is not the primary pathophysiological process involved in BRCA1 and BRCA2 genetic testing. The main purpose of these tests is to identify genetic mutations that increase the risk of developing certain types of cancer.
Choice B rationale
BRCA1 and BRCA2 do play a role in protecting mature, functioning breast and ovarian cells. However, this is not the primary reason for conducting BRCA1 and BRCA2 genetic testing. The main purpose of these tests is to identify mutations that increase cancer risk.
Choice C rationale
This is the correct answer. Mutations in BRCA1 or BRCA2 can significantly increase a person’s risk for developing breast and ovarian cancer. Therefore, identifying these mutations through genetic testing can help determine a person’s cancer risk.
Choice D rationale
While inherited mutations in BRCA1 and BRCA2 can influence the prognosis of breast cancer, the primary purpose of BRCA1 and BRCA2 genetic testing is to identify mutations that increase cancer risk, not to determine prognosis.
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