After receiving a hand-off report what assessment information is the most important and immediate concern for the nurse? Select all that apply.
Appointment the next day
Low oxygen saturation
Previous injection drug user and alcohol misuse
Has productive cough severe enough to keep her awake
Marital status
Fever is present.
Elevated temp. pulse, and respiratory rate
Diagnosis pneumonia
Daughter's name
Correct Answer : B,C,D,G,H
Low oxygen saturation: Low oxygen saturation indicates a potential respiratory compromise and should be addressed promptly to ensure adequate oxygenation and prevent further deterioration.
Previous injection drug user and alcohol misuse: Past injection drug use and alcohol misuse can have significant implications for the patient's health, including increased risk of infections, compromised immune function, and potential withdrawal symptoms. It is crucial for the nurse to be aware of these factors in order to provide appropriate care and support. Has productive cough severe enough to keep her awake: A severe productive cough that disrupts the patient's sleep suggests respiratory distress or possible worsening of the underlying condition. The nurse should assess the patient's respiratory status and implement interventions to alleviate the cough and improve rest.
Elevated temperature, pulse, and respiratory rate: An elevation in vital signs, including temperature, pulse, and respiratory rate, can indicate an infectious or inflammatory process. This warrants further assessment and intervention to manage the underlying condition. Diagnosis pneumonia: The diagnosis of pneumonia indicates a respiratory infection that requires close monitoring and appropriate treatment. The nurse should assess the patient's respiratory status, administer prescribed medications, and implement respiratory hygiene measures.
The following options are not immediate concerns or relevant assessment information:
Appointment the next day: While follow-up appointments are important, they do not require immediate attention upon receiving a hand-off report.
Marital status: Marital status is not typically an immediate concern for the nurse's assessment and care planning.
Daughter's name: The patient's family member's name is not an immediate concern or relevant assessment information for the nurse's immediate care.
Fever is present: While a fever is a symptom of an underlying condition, it is not the most critical concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Gentamicin is an antibiotic that is usually administered via IV infusion. The peak level is the highest concentration of the medication in the bloodstream, and it is important to monitor it to ensure therapeutic levels are achieved without reaching toxic levels.
Drawing the peak level 30 minutes after the infusion is complete allows enough time for the medication to distribute throughout the body and reach its peak concentration. This timing provides an accurate representation of the highest drug concentration in the bloodstream. 30 minutes before starting the infusion: Drawing the peak level before starting the infusion would not accurately reflect the peak concentration of the medication in the bloodstream. Immediately before the next dose of Gentamicin: Drawing the peak level immediately before the next dose would not provide an accurate assessment of the highest drug concentration, as the levels would have started to decrease due to elimination.
1 hour after infusion is complete: Waiting for 1 hour after the infusion is complete may result in missing the actual peak concentration of the medication in the bloodstream, as it may have already started to decline.
Correct Answer is A
Explanation
Aminophylline is a bronchodilator that belongs to the xanthine derivative class of medications. It works by relaxing the smooth muscles surrounding the bronchial airways, which leads to bronchodilation. By dilating the airways, aminophylline helps to relieve bronchospasm, improve airflow, and facilitate easier breathing.
Prevent Infection: Aminophylline is not an antimicrobial medication, and its primary action is not related to preventing or treating infections.
Suppress the cough: While aminophylline may have some antitussive (cough-suppressing) effects, its primary action is bronchodilation rather than directly suppressing the cough reflex. Promote Expectoration: Aminophylline is not primarily indicated for promoting expectoration (bringing up mucus). It mainly focuses on bronchodilation to improve airflow and relieve bronchospasm.
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