A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Administer oxygen to the client.

Notify the charge nurse.

Document client findings and interventions taken.

Place the client in high Fowler's position.

Answer and Explanation

The Correct Answer is D,A,B,C

D. Place the client in high Fowler’s position. Positioning the client upright maximizes lung expansion and improves oxygenation. This is the first step to alleviate respiratory distress before additional interventions.

A. Administer oxygen to the client. Once the client is positioned appropriately, providing supplemental oxygen helps increase oxygen saturation and relieve hypoxia. The nurse should titrate oxygen as needed according to facility protocols or provider orders.

B. Notify the charge nurse. After immediate interventions are in place, the nurse should inform the charge nurse to ensure further assessment and necessary medical interventions. The charge nurse may escalate care or contact the provider for additional management.

C. Document client findings and interventions taken. Once the client’s condition has been addressed and reported, documentation is necessary to record assessment findings, interventions provided, and the client's response. Accurate documentation ensures continuity of care and legal protection.

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Correct Answer is C

Explanation

A. Time. The prescription states that erythromycin should be administered four times per day, which is a standard frequency for this medication. No clarification is needed unless there are specific timing concerns, such as administration with or without food.
B. Medication. Erythromycin is a commonly prescribed macrolide antibiotic used for bacterial infections. Since the medication itself is clearly stated, there is no need to clarify this aspect of the prescription.
C. Route. The prescription does not specify the route of administration (e.g., oral, intravenous, or topical). Since erythromycin is available in multiple forms, including oral tablets, capsules, liquid suspension, and intravenous formulations, it is essential to clarify the intended route with the provider before administration.
D. Dosage. A dose of 500 mg four times per day is a typical dosage for erythromycin in treating infections. Unless there are concerns regarding the client’s renal or hepatic function or potential drug interactions, the dosage does not require clarification.

A. "Our child has increased his daily caloric intake." B. "Our child is able to complete his homework on time." C. "Our child has a better grasp of reality." D. "Our child has lost some weight since his last appointment."

Correct Answer is B

Explanation

A. "Our child has increased his daily caloric intake." Methylphenidate is a stimulant that commonly suppresses appetite, leading to decreased caloric intake and potential weight loss. An increase in appetite would not indicate medication effectiveness but might suggest the dose is too low or the medication is wearing off.
B. "Our child is able to complete his homework on time." Methylphenidate is used to improve attention, impulse control, and focus in children with ADHD. The ability to complete tasks, such as finishing homework on time, demonstrates improved concentration and executive functioning, which indicates the medication is working effectively.
C. "Our child has a better grasp of reality." ADHD is not primarily associated with a loss of reality testing, as seen in psychotic disorders. While methylphenidate improves focus and impulse control, it does not target symptoms such as delusions or hallucinations.
D. "Our child has lost some weight since his last appointment." Weight loss is a common side effect of methylphenidate due to appetite suppression. While this can be monitored, it does not indicate medication effectiveness in treating ADHD symptoms.

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A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is transcribing a client's prescription for erythromycin 500 mg four times per day. Which of the following information should the nurse clarify with the provider?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with the parents of a child who has ADHD and is taking methylphenidate. Which of the following statements by the parents indicates that the medication is effective?

Correct Answer is B

Explanation

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