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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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Correct Answer is B

Explanation

A. Replacing the IV site with a smaller gauge does not address the immediate concern of the non-occlusive dressing. The priority is to ensure the current dressing is secure to prevent infection and complications.
B. Redressing the abdominal incision is the most important intervention to protect the surgical site, especially since the dressing is no longer occlusive, which could lead to infection or other complications.
C. Applying soft bilateral wrist restraints is a last resort and can be seen as a restrictive measure. It is better to address the root cause of the behavior before considering restraints.
D. Leaving the lights on might not directly address the client's behavior or the issues with the abdominal dressing and IV line. It may not be as effective as addressing the specific problems at hand.

A. Blood glucose of 90 mg/dL (5 mmol/L). B. Potassium level of 4 mEq/L (4 mmol/L). C. Hemoglobin level of 13 g/dL (130 g/L). D. Serum creatinine of 5 mg/dL (442 μmol/L).

Correct Answer is D

Explanation

A. Blood glucose of 90 mg/dL (5 mmol/L): This glucose level is within the normal range and does not require immediate attention prior to surgery.
B. Potassium level of 4 mEq/L (4 mmol/L): This potassium level is normal. While potassium balance is important, this value does not indicate an immediate concern.
C. Hemoglobin level of 13 g/dL (130 g/L): This hemoglobin level is within the normal range for most adults. It is not a critical finding for reporting to the surgeon.
D. Serum creatinine of 5 mg/dL (442 μmol/L): This elevated creatinine level indicates significant renal impairment. It is crucial to report this finding as it may impact the client's ability to metabolize and excrete anesthetic agents and medications used during and after surgery.

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

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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

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