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 D
Explanation
A. While patients with latent TB may be treated to prevent progression to active TB, the treatment duration is generally shorter—typically around 3 to 9 months, depending on the medication regimen (e.g., isoniazid for 9 months or rifampin for 4 months).
B. Individuals with latent TB will usually test positive on a Mantoux test (also known as a tuberculin skin test), indicating they have been exposed to the TB bacteria. However, those with latent TB do not have active disease and may not have symptoms.
C. Individuals with latent TB do not spread the bacteria to others because the infection is contained and does not cause active disease. Only those with active TB can transmit the bacteria, regardless of sputum test results.
D. Patients with latent TB are not contagious and cannot spread the bacteria to others. The bacteria remain inactive in the body, and only a small percentage of these individuals may develop active TB in the future.
Correct Answer is D
Explanation
A. Oxygen therapy may be indicated if the patient shows signs of respiratory distress or has low oxygen saturation levels, but it does not address the underlying pain or dehydration associated with the crisis.
B. Blood transfusions can be an effective treatment for severe complications of sickle cell disease, including acute chest syndrome or severe anemia. However, transfusions are not typically the immediate priority in the early management of a sickle cell crisis unless there is a clear indication of severe anemia or complications.
C. IV fluid therapy is crucial for managing dehydration, which can exacerbate sickle cell crises. Adequate hydration helps reduce blood viscosity and can alleviate some symptoms. However, while important, fluid therapy alone does not address the immediate and often severe pain that patients experience.
D. Pain management is the top priority in the management of a patient in a sickle cell crisis. Patients often experience severe pain due to vaso-occlusive events, and addressing pain is essential for patient comfort and quality of care.
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