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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale
A. Using water with 5% dextrose (DW) is appropriate for irrigating certain types of catheters, especially those that require a non-saline solution to maintain patency. However, the choice of irrigation solution should be based on the specific type of catheter and the facility's policies. It does not directly address the immediate issue of the luer-lock syringe.
B. Sending someone else to gather equipment may be necessary in some situations but does not address the current issue of the nurse preparing to irrigate with a luer-lock tipped syringe. This option delays addressing the immediate concern.
C. Applying povidone (such as povidone-iodine solution) to the site is a step in the preparation for aseptic technique but does not address the specific issue of the syringe type or the irrigation process itself.
D. Luer-lock syringes are commonly used for irrigation purposes because they securely attach to irrigation ports, preventing accidental disconnection during the procedure. Directing the nurse to attach the luer-lock syringe ensures that the irrigation can be performed safely and effectively.
Correct Answer is A
Explanation
Rationale
A. This instruction is relevant because alcohol, particularly beer and wine, can exacerbate gout symptoms due to their purine content, which can lead to increased uric acid levels in the blood. High uric acid levels can contribute to gouty arthritis flare-ups.
B. This instruction promotes a healthier dietary choice, as carbonated drinks often contain added sugars and contribute to excess calorie intake, which can contribute to obesity. However, fruit juices can also be high in sugars and should be consumed in moderation. Encouraging water as the primary beverage choice would be even better for weight loss and overall health.
C. This instruction is generally beneficial for maintaining joint mobility and preventing stiffness, which can be particularly important for someone experiencing pain in a weight-bearing joint like the ankle. However, if the pain is severe and acute, active range of motion exercises may need to be introduced gradually and under guidance to avoid exacerbating the condition.
D. Heat therapy can provide symptomatic relief for joint pain associated with conditions like gouty arthritis. However, it is important to ensure that heat is not applied during acute inflammation or gout flare-ups, as it can potentially worsen symptoms. Cold therapy may be more appropriate during active inflammation.
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