A patient presents to the emergency department with acute respiratory distress and a high fever. Which of the following should the nurse prioritize?
Administering antipyretics immediately.
Taking a detailed medical history.
Administering intravenous fluids.
initiating oxygen therapy.
The Correct Answer is D
A. Administering antipyretics immediately: Treating fever is important for comfort and preventing complications, but it does not address the patient’s immediate threat of hypoxia or respiratory distress. Fever management is secondary to airway and oxygenation.
B. Taking a detailed medical history: Gathering history is important for diagnosis and treatment planning, but it does not immediately relieve respiratory compromise. Delaying interventions for history could endanger the patient.
C. Administering intravenous fluids: IV fluids may be necessary for hydration or shock management, but they do not directly improve oxygenation in acute respiratory distress. Fluid administration is not the first priority unless signs of hypoperfusion are present.
D. Initiating oxygen therapy: Oxygen therapy directly addresses hypoxemia and respiratory distress, which are life-threatening conditions. Ensuring adequate oxygenation is the first priority according to the ABCs (Airway, Breathing, Circulation) of emergency care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Respiratory rate measured at 22/min is observable, measurable, and obtained through direct assessment by the nurse. Objective data are factual findings that can be seen, heard, felt, or measured independently of the client’s perception.
B. Feeling anxious is a personal emotional experience described by the client. Subjective data rely on the client’s verbal report and cannot be directly measured or validated by the nurse.
C. Pain rated as 3 out of 10 reflects the client’s personal perception of discomfort. Although a scale is used, pain intensity is subjective because only the client can describe it.
D. Information provided by the partner is still based on reported experience rather than direct measurement by the nurse. This makes it subjective data, even though it comes from a secondary source.
Correct Answer is D
Explanation
A. Provide nutritional supplements instead of accommodating cultural preferences: While supplements may meet nutritional needs, ignoring cultural preferences can reduce patient satisfaction and adherence to dietary recommendations, potentially impacting overall care.
B. Advise the patient to follow the hospital's standard meal plan: Forcing standard meals without considering cultural restrictions may cause distress, reduce intake, and compromise nutritional status. Respecting cultural needs supports holistic care.
C. Request the patient to bring meals from home to avoid complications: While bringing food from home may help, it may not meet the hospital’s safety standards or provide balanced nutrition. This is not a sustainable or controlled solution.
D. Collaborate with the dietary team to ensure meals align with the patient's cultural preferences: Partnering with the dietary team allows the patient’s cultural practices to be respected while maintaining safe, balanced nutrition. This promotes adherence, satisfaction, and holistic patient-centered care.
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