Exhibits

After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions.

Which 2 prescriptions should the nurse complete first?

Perform pulmonary function test

Measure vital signs

Provide a regular diet tray

Give albuterol as ordered

Apply oxygen 1 L/minute

Answer and Explanation

Correct Answer : D,E

A.   Perform pulmonary function test
This is important for assessing lung function, but it is not an immediate priority during an acute exacerbation when the patient's oxygen saturation is low and they are experiencing respiratory distress.
Pulmonary function testing can be done once the patient's acute symptoms are stabilized.
B.   Measure vital signs
While vital signs are important for ongoing assessment, the patient's vital signs were already assessed at admission and are being monitored every 4 hours as per orders.
Administering oxygen and albuterol to stabilize the patient's condition takes precedence over routine vital sign checks immediately after the initial assessment.
C.   Provide a regular diet tray
This is a routine aspect of care and does not address the acute respiratory distress or hypoxemia that require immediate attention.
It can be done once the patient's respiratory status has stabilized.
D.   Give albuterol as ordered
The patient is experiencing an asthma exacerbation with wheezing and subcostal retractions. Albuterol is a bronchodilator that helps relieve bronchospasm and improve airflow.
It was ordered for nebulization now and every 4 hours PRN (as needed) for wheezing.
Administering albuterol promptly is crucial to help alleviate respiratory distress and improve lung function.
E.   Apply oxygen 1 L/minute
The patient's oxygen saturation is 91% on room air, which is below the target of greater than 94%. Oxygen therapy is indicated to correct hypoxemia and improve oxygen saturation.
The order specifies to titrate oxygen to keep saturation greater than 94%, starting at 1 L/minute via nasal cannula.

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Correct Answer is B

Explanation

Rationale

A. This action involves assessing the capillary refill of the lower extremity distal to the femoral site. It helps in evaluating peripheral perfusion and circulation to ensure there is no compromise to blood flow. This is important because decreased capillary refill could indicate impaired circulation, possibly due to arterial occlusion or hematoma formation.

B. Checking the femoral insertion site for hematoma formation is crucial after a cardiac catheterization. Hematomas can develop due to bleeding from the femoral artery puncture site, especially if the client is receiving anticoagulant therapy like heparin. A hematoma can compress surrounding structures, potentially causing pain and compromising circulation.

C. While it's important to assess the integrity of IV insertion sites, in this scenario, the primary concern is the groin insertion site used for cardiac catheterization. The IV insertion sites should be assessed regularly for signs of infiltration, phlebitis, or infection, but this should not take precedence over assessing the femoral insertion site for complications related to the procedure.

D. Deep breathing exercises are important for preventing respiratory complications such as atelectasis and pneumonia, especially in clients who are sedated and immobilized. However, in the context of acute pain at the femoral insertion site post-cardiac catheterization, assessing and addressing potential complications related to the procedure take priority.

A. Move Client D into an isolation room 24 hours before surgery. B. Verify that Client B has two units of packed cells available. C. Ask the dietitian to add a banana to Client C's breakfast tray. D. Increase Client A's oxygen to 4 L/minute via nasal cannula.

Correct Answer is B

Explanation

Rationale

A. Client A's oxygen saturation is acceptable for someone with emphysema.

B. This is because Client B's postoperative hemoglobin level is 8.2 mg/dL, which is significantly lower than the normal reference range of 14 to 18 g/dL. This indicates that Client B is anemic and may require a blood transfusion to increase the hemoglobin level.

C. Client C's potassium level is within the normal range

D. Client D's WBC count is elevated, moving them into isolation is not indicated solely based on an elevated WBC count.

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Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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Exhibits

After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions.

Which 2 prescriptions should the nurse complete first?