What 2 orders should the nurse complete first?
Chesty
Start oxygen 3 L via nasal cannula
Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3")
Normal saline 150 mi/hour
NPO
Start a IV
Sputum culture
Place the client on a cardiorespiratory monitor
Correct Answer : B,H
A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.
B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.
E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.
H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
A. Teach the client how to count carbohydrates - Non-urgent. While essential for long- term management of diabetes, carbohydrate counting is not immediately critical in the acute management phase of HHS in the ICU. This teaching should be delayed until the patient is stabilized.
B. Stop the insulin infusion - Contraindicated. Stopping insulin in a patient with HHS, which is characterized by severe hyperglycemia, would be harmful. Insulin therapy is critical to reduce blood glucose levels safely.
C. Decrease the frequency of blood glucose tests - Contraindicated. Frequent monitoring is crucial in managing HHS, especially when insulin therapy is being administered, to prevent hypoglycemia and to monitor the effectiveness of treatment.
D. Start the client on a regular diet - Contraindicated. Introducing a regular diet during the acute phase of HHS could exacerbate the hyperglycemia. Nutritional needs should be assessed and managed carefully, typically starting with IV fluids and gradually transitioning to enteral or oral feeding as the patient stabilizes.
E. Decrease the insulin IV infusion to 0.05 units/kg/hr- Indicated. As blood sugar levels decrease, the insulin infusion rate may be cautiously reduced to prevent hypoglycemia.
Correct Answer is A
Explanation
A. An aPTT that is 2 times the control value indicates that the heparin is effectively anticoagulating the blood, which is a desired outcome in managing MI to prevent clot formation.
B. S3 heart sounds can indicate heart failure and are not a sign of a satisfactory response to MI treatment.
C. Wide Q waves indicate a previous infarction but do not reflect the immediate effectiveness of the treatment.
D. A positive guaiac test indicates gastrointestinal bleeding, which is a potential complication rather than a satisfactory response.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.