A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse’s priority intervention?

Obtain a sputum sample.

Arrange transport for radiographic imaging.

Move the patient into airborne isolation.

Collect specimens for blood cultures.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Obtaining a sputum sample is important for diagnosing respiratory infections, but it is not the priority intervention in this case. The patient’s symptoms of intermittent fever, night sweats, and a productive cough with small amounts of blood are indicative of a possible airborne disease such as tuberculosis.
Choice B rationale
Arranging transport for radiographic imaging can be helpful in diagnosing the patient’s condition, but it is not the immediate priority. The primary concern should be to prevent the potential spread of an airborne disease.
Choice C rationale
Moving the patient into airborne isolation is the priority intervention. This action is taken to prevent the spread of potential airborne diseases to other patients and healthcare workers.
Choice D rationale
Collecting specimens for blood cultures can help identify the causative organism if the patient has a systemic infection. However, given the patient’s symptoms and the potential for an airborne disease, moving the patient into isolation is the priority.

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Free Nursing Study Resources

Correct Answer is ["125"]

Explanation

Step 1 is to convert the volume of the prescription from liters to milliliters. 1 liter is equal to 1000 mL. So, the prescription is for 1000 mL of lactated Ringer’s.

Step 2 is to divide the total volume by the total time. The prescription is to be infused over 8 hours. So, 1000 mL ÷ 8 hours = 125 mL/hr. Therefore, the nurse should program the infusion pump to deliver 125 mL/hr.

A. Take prescribed cortisone accurately. B. Use a walker when weakness occurs. C. Avoid extreme environmental temperatures. D. Increase daily intake of sodium in diet.

Correct Answer is A

Explanation

Choice A rationale
Taking prescribed cortisone accurately is the most important instruction for a client diagnosed with Addison’s disease. Cortisone is a type of glucocorticoid replacement therapy that helps to manage the symptoms of Addison’s disease and prevent adrenal crisis, a life-threatening condition characterized by acute insufficiency of adrenal hormones.
Choice B rationale
Using a walker when weakness occurs may be helpful for some clients with Addison’s disease, as muscle weakness is a common symptom. However, it is not the most important instruction. The primary treatment for Addison’s disease is hormone replacement therapy, which should help to alleviate symptoms such as muscle weakness.
Choice C rationale
Avoiding extreme environmental temperatures can be beneficial for individuals with Addison’s disease, as they may have difficulty regulating body temperature due to cortisol deficiency.
However, this is not the most important instruction. The cornerstone of managing Addison’s disease is hormone replacement therapy.
Choice D rationale
Increasing daily intake of sodium in the diet can be beneficial for some individuals with Addison’s disease, particularly during periods of gastrointestinal illness or intense physical activity. However, this is not the most important instruction. The primary treatment for Addison’s disease is hormone replacement therapy.

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A patient has arrived at the emergency department reporting intermittent fever and night sweats for the past three weeks and has developed a cough that is productive with small amounts of blood. What should be the nurse’s priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for 1 liter of lactated Ringer’s intravenously (IV) to be infused over 8 hours. The IV administration set delivers 15 gtt/mL. How many mL/hr should the nurse program the infusion pump to deliver?

Correct Answer is ["125"]

Explanation

The nurse is preparing a client for discharge who was recently diagnosed with Addison’s disease. Which instruction is most important for the nurse to include in this client’s discharge teaching plan?

Correct Answer is A

Explanation

A patient with small cell carcinoma of the lung is admitted with syndrome of inappropriate antidiuretic hormone (SIADH). The patient’s serum sodium level increases from 120 mEq/L to 125 mEq/L as they respond to treatment. Based on this finding, what intervention should the nurse implement?

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