Exhibits

In what order will the nurse implement these interventions?

Tylenol 650 mg PO prn q6h for a temperature above 101° F

Blood cultures x 2, taken 5 minutes apart

C&S of abdominal wound drainage

Vancomycin 750 mg IVPB over 1 hour every 24 hour

Answer and Explanation

The Correct Answer is B,A,D,C

B. Blood cultures x 2, taken 5 minutes apart – First Priority: Blood cultures must be obtained before administering antibiotics to accurately identify the causative organism. In a patient showing signs of sepsis—hypotension, tachycardia, tachypnea, fever, and purulent wound drainage—early culture collection is critical to guide effective therapy.

A. Tylenol 650 mg PO prn q6h for a temperature above 101°F – Second: Fever management improves patient comfort and reduces metabolic demand but is not immediately life-saving. It is appropriate to administer after cultures are drawn.

D. Vancomycin 750 mg IVPB over 1 hour every 24 hours – Third: Broad-spectrum IV antibiotics should be started immediately after cultures are obtained. Early administration is essential to treat sepsis and prevent progression to septic shock, while still ensuring culture results are accurate.

C. C&S of abdominal wound drainage – Fourth: Wound culture helps tailor ongoing antibiotic therapy but is secondary to the urgent need to obtain blood cultures and start empiric antibiotic therapy.

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Correct Answer is C

Explanation

A. An increased respiratory rate indicates worsening distress, but it is a less specific markerof impending respiratory failure compared with silent chest or absent breath sounds.

B. Louder wheezing may indicate bronchospasm, but paradoxically, in severe asthma, as airflow diminishes, wheezing may decrease or disappear, signaling critical airflow obstruction, not improvement.

C. Diminished or absent breath sounds indicate severe airway obstruction with minimal airflow, a hallmark of status asthmaticus. This is a life-threatening sign requiring immediate escalation, such as intubation and advanced airway management.

D. Subjective improvement may be misleading. Patients can feel temporarily better due to increased effort or hyperventilation, but objective findingslike silent chest take priority in identifying impending respiratory failure.

A. Add pulmonary toileting to daily interventions. B. Instruct the AP to sit with the client until she is calmer. C. Call the respiratory therapist for a bronchodilator treatment. D. Suction the artificial airway and remove the secretions.

Correct Answer is D

Explanation

A. Pulmonary hygiene (such as chest physiotherapy, nebulizers, or routine suctioning) is essential for long-term prevention of secretion buildup, but it is not an acute intervention. Waiting to schedule routine care would delay relief of an active obstruction, putting the client at risk.

B. Providing emotional support can reduce anxiety and may indirectly help with breathing patterns, but it does not remove the airway obstruction. The physiologic threat of hypoxia takes precedence over comfort measures.

C. Bronchodilators can improve airway patency over time, especially in clients with bronchospasm, but they do not remove existing thick secretions. Delaying suctioning while waiting for bronchodilator therapy would allow oxygenation to worsen.

D. This action directly addresses the immediate riskby clearing the airway, improving oxygenation, and reducing the work of breathing. After suctioning, the nurse can reassess SpO2, lung sounds, respiratory rate, and work of breathing to evaluate the client’s response. Continuous monitoring after suctioning is critical, as secretions may quickly accumulate again, especially in clients with tracheostomies or underlying pulmonary conditions.

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Exhibits In what order will the nurse implement these interventions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

As the assessment is completed, the nurse observes that the client has a large amount of thick secretions visible in the trach. What is the priority nursing action?

Correct Answer is D

Explanation

The nurse is assessing a client who is in shock. Which of the following findings would indicate to the nurse that the client is entering an irreversible stage?

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Which assessment finding in a client in the refractory phase of shock requires immediate nursing intervention?

When caring for four clients, which does the nurse identify as at the highest risk for frostbite?

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The nurse is caring for a client in the emergency room who has been diagnosed with shock. The client has a history of an abscessed tooth that has not yet been removed. Which type of shock does the nurse suspect?

Exhibits

In what order will the nurse implement these interventions?