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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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. A blood alcohol level of 0.09% indicates intoxication but is less immediately critical than lithium toxicity.
B. A serum lithium level of 1.6 mEq/L indicates lithium toxicity, which can be life- threatening and requires immediate medical intervention.
C. Significant weight loss is concerning but not as acute an issue as potential lithium toxicity.
D. Lack of sleep is serious but is a symptom that can be managed; it is not as urgent as addressing potential lithium toxicity.

A. Administering antipyretic medication as needed B. Educating client and family on the importance of fluid restrictions C. Collaborating with dietician to prepare low protein diet D. Monitoring fluid status E. Investigating acid/base complication F. Assessing for worsening respiratory status G. Performing diagnostic testing to determine cause of fever H. Reassessing vital signs I. Identifying cardiac arrhythmias

Correct Answer is ["D","F","I"]

Explanation

A. Administering antipyretic medication as needed is important for managing the client's fever and improving comfort, but not as urgent as monitoring fluid, respiratory status, and cardiac function.
B. Client and family education on fluid management is important but can be addressed after assessing hydration status.
C. Protein restriction might be necessary for CKD management in the long term, but not the most pressing need right now.
D. Given the client's history of chronic kidney disease, monitoring fluid status is crucial to prevent fluid overload and ensure adequate kidney function. Accurate intake and output measurements, along with daily weights, are essential.
E. The bicarbonate level (18 mEq/L) is slightly low, but further investigation can come after addressing the infection.
F. The chest X-ray shows bibasilar infiltrates, and the client has a high respiratory rate.

Continuous assessment of respiratory status is important to detect any signs of respiratory distress or infection, which may require immediate intervention.
G. Performing diagnostic testing to determine cause of fever is necessary for identifying the underlying infection, but secondary to immediate stabilization efforts.
H. Reassessing vital signs is vital for ongoing assessment, but integrated into the monitoring of fluid status, respiratory status, and cardiac function.

I. The client has an elevated potassium level and an irregular heart rate, putting him at risk for cardiac arrhythmias. Continuous ECG monitoring and immediate identification of any arrhythmias are critical to prevent cardiac complications.

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What 2 orders should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Correct Answer is ["D","F","I"]

Explanation

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