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. 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.

A. Phenazopyridine B. Phentolamine C. Vitamin B6 (Pyridoxine) D. Pyrazinamide

Correct Answer is C

Explanation

A. This medication is used primarily to relieve urinary tract discomfort and does not have any role in preventing peripheral neuropathy associated with INH. It is not relevant in this context.
B. Phentolamine is an alpha-adrenergic antagonist used to treat hypertension and manage pheochromocytoma. It has no association with preventing peripheral neuropathy related to INH and is not appropriate for this patient.
C. Isoniazid can cause peripheral neuropathy by interfering with the metabolism of pyridoxine (Vitamin B6). Administering pyridoxine can help prevent this side effect by replenishing the vitamin and supporting nerve health.
D. Pyrazinamide is another anti-tuberculosis medication that works alongside INH. While it is effective for tuberculosis, it does not prevent peripheral neuropathy and may even have its own side effects.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with iron deficiency anemia who is taking oral iron supplements is evaluated by the nurse in the outpatient clinic. Which finding by the nurse is of MOST concern?

Correct Answer is B

Explanation

An RN is caring for a patient with Tuberculosis who is to receive a new prescription for Isoniazid (INH). The nurse knows that INH can cause peripheral neuropathy. To help prevent this from happening, the nurse can ask the provider for:

Correct Answer is C

Explanation

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