A nurse is caring for a patient who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing PRIORITY?

Obtain a sputum culture

Obtain baseline vital signs and oxygen saturation

Obtain a complete history from the client

Provide the PCV vaccine

Answer and Explanation

The Correct Answer is B

A.   While obtaining a sputum culture is important for diagnosing a potential respiratory infection, it is not the immediate priority. The patient’s vital signs and oxygenation status need to be assessed first to ensure safety and to inform clinical decisions.
B.   Assessing the patient’s vital signs and oxygen saturation is critical in this situation. The symptoms of disorientation, chills, and chest pain could indicate a serious condition such as pneumonia or pulmonary embolism.
C.   Gathering a complete history is valuable for understanding the patient's condition and underlying causes of symptoms. However, this action should follow immediate assessments of vital signs and oxygen saturation, especially in a potentially unstable patient.
D.   Administering the pneumococcal vaccine is important for prevention but is not an urgent action in this acute situation. The patient’s current symptoms require immediate assessment and intervention rather than preventive measures.

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Correct Answer is B

Explanation

A. Diabetes Insipidus is primarily related to issues with the production of vasopressin (ADH) or the body's response to it, which is not directly caused by CKD. CKD may lead to fluid retention and imbalances, but it does not typically cause recurrent bouts of diabetes insipidus.
B. In CKD, the kidneys lose their ability to produce erythropoietin, a hormone that stimulates red blood cell production in the bone marrow. Patients often require erythropoiesis-stimulating agents (ESAs) like erythropoietin injections to manage anemia associated with CKD.
C. CKD patients are often hyperkalemic (high potassium levels) rather than hypokalemic. As kidney function declines, the kidneys struggle to excrete potassium, leading to elevated levels, which can cause serious complications.
D. CKD patients often experience hypocalcemia (low calcium levels) due to several factors, including decreased activation of vitamin D and imbalances in phosphate levels. While some patients may experience transient hypercalcemia due to treatments or dietary factors, chronic hypercalcemia is not typical in CKD.

A. Leukocytosis B. Left shift C. Erythrocytosis D. Neutropenia

Correct Answer is A

Explanation

A. Leukocytosis refers to an elevated white blood cell (WBC) count, typically above the normal range (approximately 4,000 to 10,000 WBCs per microliter of blood). A count of 22,000 indicates leukocytosis, which may be due to infection, inflammation, stress, or other conditions.
B. A left shift refers to an increase in immature white blood cells, particularly neutrophil precursors, in the bloodstream. It often indicates an acute infection or inflammatory response. While the WBC count of 22,000 may suggest a left shift, it does not confirm it without further analysis of the differential count of the WBCs.
C. Erythrocytosis is an increase in red blood cells (RBCs), not white blood cells. Therefore, this option is incorrect. A high WBC count does not indicate changes in red blood cell levels.
D. Neutropenia refers to a decreased number of neutrophils, which are a type of white blood cell. Given the WBC count of 22,000, neutropenia is not applicable and is therefore incorrect.

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A nurse is caring for a patient who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing PRIORITY?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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