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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. This is primarily associated with Systemic Lupus Erythematosus (SLE), not Rheumatoid Arthritis. While some RA patients may have skin changes, a malar rash is not a typical manifestation of RA.
B. Morning stiffness is a hallmark symptom of Rheumatoid Arthritis. Patients often experience stiffness in their joints after periods of inactivity, particularly in the morning, which typically lasts for at least 30 minutes and can improve with movement.
C. Swan neck deformities are specific joint deformities seen in RA, where there is hyperextension of the proximal interphalangeal joints and flexion of the distal interphalangeal joints. This is a common feature in advanced cases of RA.
D. : RA typically presents with symmetrical joint involvement. This means that if one side is affected, the opposite side is likely to be similarly affected, leading to bilateral joint deformities.
E. While joint pain can occur at rest, RA is more characterized by pain and stiffness during periods of inactivity and improvement with movement. However, as the disease progresses, patients may experience pain even at rest.
Correct Answer is B
Explanation
A. While taking a multivitamin can provide additional nutrients, it is generally not a cause for concern unless the multivitamin contains high doses of certain minerals that might interact negatively with iron absorption. However, this is less pressing compared to the interaction between antacids and iron.
B. Antacids can significantly interfere with the absorption of oral iron supplements, leading to inadequate treatment of iron deficiency anemia. This is the most concerning finding because it may negate the effectiveness of the iron supplementation, making it harder for the patient to improve their iron levels.
C. Black stools are a common and expected side effect of iron supplementation due to the presence of unabsorbed iron in the gastrointestinal tract. While the nurse should monitor for this, it is not inherently concerning as it indicates that the iron is being ingested.
D. Constipation is a common side effect of iron supplements. Although it can be uncomfortable, it is not as critical as the potential interference caused by taking antacids. Management strategies can often alleviate this side effect.
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