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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Correct Answer is B

Explanation

Choice A rationale
Starting an intravenous infusion for antiviral drug administration is premature at this stage. The patient’s COVID-19 test results are not yet available, and antiviral drugs should not be administered without a confirmed positive test.
Choice B rationale
Moving the patient to a private room, keeping the door closed, and initiating droplet precautions is the most important action. Given the patient’s symptoms and the significant other’s COVID-19 status, these measures will help prevent potential spread of the virus.
Choice C rationale
Notifying the charge nurse for assignment to the COVID-19 specified area of the facility is important, but it is not the immediate priority. The first step should be to initiate droplet precautions to minimize the risk of transmission.
Choice D rationale
While it is important to inform the patient about potential exposure, the immediate priority is to prevent the spread of the virus within the healthcare facility.

A. Activity level of bowel sounds. B. Level and amount of physical activity. C. Eating patterns of dietary intake. D. Color and consistency of feces.

Correct Answer is C

Explanation

Choice A rationale
While the activity level of bowel sounds can provide information about the functioning of the gastrointestinal system, it is not the most important data to manage the patient’s pain from chronic pancreatitis.
Choice B rationale
The level and amount of physical activity can affect the patient’s pain level, but it is not the most crucial data for managing pain in chronic pancreatitis.
Choice C rationale
Eating patterns of dietary intake are the most important data to manage the patient’s pain. In chronic pancreatitis, certain foods can exacerbate the pain. Understanding the patient’s dietary habits can help in providing appropriate dietary modifications.
Choice D rationale
The color and consistency of feces can provide information about the patient’s digestive health, but it is not the most important data to manage the patient’s pain from chronic pancreatitis.

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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

Correct Answer is B

Explanation

The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient’s pain?

Correct Answer is C

Explanation

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