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The client is a 49-year old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the emergency department (ED last night when he was having more difficulty breathing hat a history of one-half pack a day cigarette smoking for years. He has no significant medical or surgical history

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. While monitoring urinary output is important, it is not the most critical assessment in this context.
B. Monitoring serum electrolytes is crucial because the large amount of fecal liquid output from the ileostomy can lead to significant electrolyte imbalances.
C. Peristomal skin integrity is important but is secondary to the immediate risk of electrolyte imbalances.
D. Skin turgor is important for assessing hydration status, but monitoring electrolytes is more directly related to the immediate postoperative care.

A. Encourage sitting up and ambulation B. Monitor for bleeding once daily C. Use Incentive spirometer every 1 hour D. Promote adequate hydration E. Assess for sedation after pain medications F. Complete neurologic assessment every 2 hours G. Administer pain medication after activity

Correct Answer is ["A","C","D","E","G"]

Explanation

A. Early ambulation helps prevent complications such as atelectasis, pneumonia, and deep vein thrombosis (DVT). It also promotes intestinal motility.
B. Monitoring for bleeding should be more frequent, especially in the immediate postoperative period, rather than just once daily.
C. This helps prevent respiratory complications such as atelectasis and promotes lung expansion.
D. Adequate hydration is essential to maintain fluid balance, promote healing, and prevent complications such as urinary tract infections and constipation.
E. Monitoring for sedation is crucial to ensure that pain medications are not causing excessive drowsiness, which could impair the client's ability to participate in activities such as ambulation and use of the incentive spirometer.

F. While assessing neurological status is important, frequent neurological assessments are more relevant for clients with neurological conditions or concerns. In this case, routine assessments should be sufficient unless the client has specific neurological symptoms.
G. Pain medications should be administered prophylactically before activity. However, it can also be administered after activity in case the client complains of pain.

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Naxlex Comprehensive Predictor Exams

Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most

Correct Answer is B

Explanation

Patient Data Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

Correct Answer is ["A","C","D","E","G"]

Explanation

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