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 ["A","D","E"]
Explanation
Choice A rationale
Teaching the client how to use guided imagery can be a helpful intervention for coping with feelings related to death and dying. Guided imagery can help the client to relax, reduce stress and anxiety, and find comfort.
Choice B rationale
Instructing the client and family to reconsider end of life choices is not typically an appropriate intervention. The nurse should respect the client’s end of life choices and provide support, rather than suggesting they reconsider.
Choice C rationale
Recording the client’s desire to live is not typically an intervention used in hospice care. The focus in hospice care is on providing comfort and quality of life, rather than on prolonging life.
Choice D rationale
Encouraging the family to bring the client old photographs can be a helpful intervention. Looking at old photographs can stimulate memories and conversations, providing comfort and connection.
Choice E rationale
Encouraging the family to visit frequently can be a beneficial intervention. Frequent visits can provide the client with emotional support and companionship, which can be comforting when coping with feelings related to death and dying.
Correct Answer is B
Explanation
Choice A rationale
Using an electric heating pad when the pain is at its worst is not recommended for a client with gout. Heat can increase inflammation and exacerbate pain. Instead, applying a cold pack to the inflamed joint can help reduce inflammation and relieve pain.
Choice B rationale
Acetylsalicylic acid, also known as aspirin, can increase uric acid levels in the blood and exacerbate gout symptoms. Therefore, clients with gout should avoid taking medications containing acetylsalicylic acid.
Choice C rationale
Consuming high-protein foods can increase uric acid levels in the blood and trigger a gout attack. Clients with gout are usually advised to follow a low-purine diet, which involves limiting the intake of high-purine foods such as red meat and seafood.
Choice D rationale
Encouraging active range of motion to limit stiffness may not be appropriate for a client with an acute gout attack. During an attack, moving the affected joint can be extremely painful. Rest and immobilization of the affected joint are usually recommended during this time.
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