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Case 1/6
Exhibits
Which 2 orders should the nurse complete first?

NPO

Acetaminophen 350 mg PO every 6 hours for temperature greater than 101° F (38.3°C)

Sputum culture

Run 0.9% sodium chloride IV infusion at 150 ml/hour

Place the client on a cardiorespiratory monitor

Chest x ray

Start oxygen 3 L/minute via nasal cannula

Start a peripheral IV

Answer and Explanation

Correct Answer : G,H

A. NPO (Nothing by Mouth) is a precaution for specific procedures or conditions but does not address the immediate needs of the client’s symptoms or diagnostic processes.
B. Acetaminophen for temperature management is important, but addressing immediate concerns for oxygenation and establishing IV access takes precedence.
C. A sputum culture is essential for diagnosis but can be done after stabilizing the client and ensuring that the client has adequate oxygenation and IV access.
D. Starting the IV infusion is crucial, but it is done after establishing oxygen therapy and monitoring.
E. Placing the client on a cardiorespiratory monitor is important for ongoing assessment but is secondary to immediate interventions for oxygenation and IV access.
F. The chest x-ray is important for diagnosis but can follow the stabilization of the client’s condition and setup for diagnostic testing.
G. Starting oxygen at 3 L/minute via nasal cannula addresses the client's immediate need for respiratory support due to difficulty breathing.
H. Starting a peripheral IV is necessary for administering medications and fluids, and should be done early in the process to prepare for other interventions.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Encourage the parents to allow the child to continue attending swimming lessons with supervision: Swimming is a low-impact exercise that can be beneficial for children with Duchenne muscular dystrophy, and supervision ensures safety.
B. Provide a list of alternative activities that are less likely to cause the child to experience fatigue: While considering fatigue is important, swimming can be a safe and beneficial activity if supervised.
C. Explain that their child is too young to understand the risks associated with swimming: The child's age is not a relevant factor; safety measures and supervision are key.
D. Suggest that the child be encouraged to participate in a team sport to encourage socialization: Team sports are not necessarily appropriate for a child with Duchenne muscular dystrophy due to potential physical strain.

A. Initiate seizure precautions. B. Measure urinary output every hour. C. Monitor serum potassium frequently. D. Assess pupillary response to light hourly.

Correct Answer is B

Explanation

A. Initiate seizure precautions: Seizure precautions are not directly related to the administration of dopamine for hypotension. Dopamine primarily affects cardiovascular function.
B. Measure urinary output every hour: Monitoring urinary output is essential because dopamine can increase renal perfusion, and adequate urine output indicates effective renal function and response to treatment.
C. Monitor serum potassium frequently: While monitoring potassium levels might be necessary in some situations, it is not a primary focus of dopamine therapy unless there are specific concerns about electrolyte imbalances.
D. Assess pupillary response to light hourly: Pupillary response is not a primary concern when administering dopamine unless there are symptoms of neurological compromise, which is not indicated in this scenario.

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Case 1/6 Exhibits Which 2 orders should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

Correct Answer is A

Explanation

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is B

Explanation

A school-aged client was recently diagnosed with type 1 diabetes mellitus. Which symptom did the client's parents most likely report?

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client's arm?

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An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Oxygen at 5 L/minute per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, which principle of oxygen administration should the nurse consider?

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Exhibits Based on the results of the echocardiogram, the physician has decided to repair the ventricular septal via cardiac catheterization. What should the nurse's focused assessment include before the cardiac catheterization? Select all that apply.

Case 1/6
Exhibits
Which 2 orders should the nurse complete first?