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. Leave the wound open for 5 to 10 days and then close with sutures: Delayed primary (tertiary) intention involves initially leaving a contaminated or high-risk wound open to allow drainage and reduce infection risk. After the wound shows no signs of infection, it is then surgically closed, promoting healing while minimizing complications.
B. Immediately close the wound with sutures to prevent infection: Primary closure of a contaminated wound increases the risk of infection because bacteria may be trapped inside. Immediate closure is inappropriate in wounds that are not clean or are at high risk for contamination.
C. Apply a hydrocolloid dressing to maintain a moist environment: Hydrocolloid dressings are suitable for clean or minimally exudative wounds. For contaminated wounds planned for tertiary intention, the priority is drainage and infection control, which may not be achieved with an occlusive dressing.
D. Use mechanical debridement to remove necrotic tissue daily: While debridement is important for necrotic tissue removal, routine daily mechanical debridement may damage healthy tissue. The primary focus in delayed primary closure is infection prevention and monitoring, rather than aggressive debridement.
Correct Answer is D
Explanation
A. Stage II: Stage II pressure injuries involve partial-thickness skin loss with exposed dermis. The injury may present as a blister, shallow ulcer, or abrasion. Since the skin in this case is intact, it does not meet Stage II criteria.
B. Stage IV: Stage IV pressure injuries are full-thickness tissue losses with exposed bone, tendon, or muscle. This severe stage is accompanied by extensive tissue damage, which is not present in this scenario.
C. Stage III: Stage III injuries involve full-thickness skin loss with damage or necrosis of subcutaneous tissue. The injury may extend down to, but not through, underlying fascia. The intact skin observed here does not qualify as Stage III.
D. Stage I: Stage I pressure injuries are characterized by non-blanchable erythema of intact skin, usually over a bony prominence. This is the earliest stage and indicates localized tissue damage without loss of skin integrity, matching the scenario described.
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