A nurse in a clinic is caring for a patient whose partner states the patient woke up this morning, did not recognize him, and did not know where she was.
The patient reports chills and chest pain that is worse upon inspiration.
Which of the following actions is the nursing priority?
Obtain a complete history from the patient.
Provide a pneumococcal vaccine.
Obtain baseline vital signs and oxygen saturation.
Obtain a sputum culture.
The Correct Answer is C
Choice A rationale
While obtaining a complete history is important for diagnosis, it is not the immediate priority. The patient's altered mental status, chest pain, and chills suggest a serious infectious or cardiopulmonary process like pneumonia, which can rapidly progress. Delaying the assessment of vital signs and oxygen saturation to gather a detailed history could be detrimental, as the patient's condition may worsen during that time.
Choice B rationale
Providing a pneumococcal vaccine is a prophylactic measure for pneumonia prevention. While potentially relevant for a patient at risk for or diagnosed with pneumonia, it is not an immediate life-saving intervention. The priority is to assess and stabilize the patient's current condition, not to prevent a future illness. Vaccination is a secondary intervention once the patient is stabilized.
Choice C rationale
The nursing priority in this situation is to obtain baseline vital signs and oxygen saturation. The patient's symptoms of altered mental status, chest pain, and chills are red flags for a serious cardiopulmonary condition like pneumonia. Assessing vital signs, including oxygen saturation, provides crucial data to determine the severity of the illness and guide immediate interventions to stabilize the patient's condition. Normal oxygen saturation is 95-100%.
Choice D rationale
Obtaining a sputum culture is a diagnostic procedure used to identify the causative organism of a respiratory infection. While an important step for guiding targeted antibiotic therapy, it is not the nursing priority. Sputum collection can be time-consuming, and the results are not immediately available. The priority is to assess the patient's current physiological status and provide supportive care, such as oxygen, if needed, based on the vital signs
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Occasional expiratory wheezes can be a sign of bronchoconstriction but do not necessarily indicate a need for immediate suctioning. Suctioning is primarily indicated for the presence of secretions that obstruct the airway, not for bronchospasm, which is typically treated with bronchodilators.
Choice B rationale
Suctioning is a procedure based on patient assessment findings, not a predetermined schedule. Performing the procedure on a timed basis, without clinical indication, can cause trauma to the tracheal and bronchial mucosa, increasing the risk of infection and bleeding.
Choice C rationale
A pulse oximeter reading of 93% is within the acceptable range for many patients and does not, by itself, indicate the need for suctioning. The need for suctioning is based on the presence of secretions, not solely on oxygen saturation levels, unless there is a significant drop in SpO$_2$.
Choice D rationale
A respiratory rate of 32 breaths/min indicates increased respiratory effort and distress. This tachypnea may be a sign of airway obstruction from secretions, which the patient is trying to clear. The nurse should perform an assessment, including auscultation, and consider suctioning. *.
Correct Answer is C
Explanation
Choice A rationale
Antibiotics are ineffective against shingles because the disease is caused by a virus, not bacteria. Shingles, or herpes zoster, is a reactivation of the varicella-zoster virus. Antibiotics target and kill bacteria by disrupting their cell walls or inhibiting protein synthesis. Administering an antibiotic would not address the viral cause of the disease and would not reduce the pain or halt its progression.
Choice B rationale
Antifungal medications are not indicated for the treatment of shingles. These drugs are specifically designed to treat infections caused by fungi by targeting the fungal cell wall or membrane. Since shingles is a viral infection, antifungal drugs would have no therapeutic effect on the varicella-zoster virus and would fail to alleviate symptoms or alter the course of the disease.
Choice C rationale
Antiviral medications are the primary treatment for shingles. These drugs, such as acyclovir, valacyclovir, and famciclovir, work by inhibiting viral DNA replication. By interrupting the viral life cycle, they can reduce the severity and duration of the outbreak, lessen the associated pain, and decrease the risk of postherpetic neuralgia. These medications are most effective when initiated within 72 hours of symptom onset.
Choice D rationale
While anti-inflammatory medications may be used to manage the pain associated with shingles, they do not halt the progression of the disease. Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids can reduce inflammation and provide symptomatic pain relief. However, they do not target the varicella-zoster virus itself. The primary treatment to stop the viral replication and disease progression is an antiviral medication. *.
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