Exhibits here
The nurse is implementing the plan of care.
For each body system, click to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.
The Correct Answer is []
Immunological Administer antihistamine
The correct answer is to administer antihistamine. Antihistamines can help alleviate symptoms of an allergic reaction, such as itching, hives, and swelling, by blocking the effects of histamine
released during the allergic response.
Cardiovascular
Monitor vital signs continuously
The correct answer is to monitor vital signs continuously. Continuous monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation, is essential to detect any changes in the client's cardiovascular status, especially after experiencing adverse reactions to medication.
Provide warmth
Providing warmth can help improve peripheral circulation and comfort for the client, especially if they are experiencing symptoms such as dizziness or feeling cold due to a drop in blood pressure.
Respiratory
Assess lung sounds
The correct answer is to assess lung sounds. Assessing lung sounds can help determine if the client is experiencing any respiratory distress or complications, such as wheezing or crackles, which may indicate a need for further intervention or respiratory support.
Chest x-ray
Ordering a chest x-ray can help evaluate the client's respiratory status, especially if there are concerns about potential complications such as pneumonia or pulmonary edema. It allows for the assessment of lung fields and can provide valuable information about the client's respiratory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Acetaminophen 350 mg PO every 6 hours for temperature greater than 101°F (38.3°C): While controlling fever is important, it is not as urgent as ensuring adequate oxygenation and
monitoring of vital signs. Fever can be managed once the client's respiratory status is stabilized.
B. Place the client on a cardiorespiratory monitor
The correct answer is B. Placing the client on a cardiorespiratory monitor is crucial to continuously monitor vital signs, including heart rate, respiratory rate, oxygen saturation, and cardiac rhythm. Given the client's reported difficulty breathing, this order takes priority to assess the severity of respiratory distress and ensure timely intervention if needed.
C. Start oxygen 3 L/minute via nasal cannula
The correct answer is C. Initiating oxygen therapy is essential for improving oxygenation and respiratory function, especially in a patient with reported difficulty breathing. Administering oxygen can help alleviate hypoxemia and reduce the workload on the respiratory system. This intervention takes precedence in addressing the client's acute respiratory symptoms.
D. Chest x-ray: A chest x-ray is important for further evaluation of the client's respiratory status, but it is not as immediate as placing the client on a cardiorespiratory monitor and initiating oxygen therapy.
E. Run 0.9% sodium chloride IV infusion at 150 mL/hour: Initiating IV fluids is important, but it is not as urgent as addressing the client's respiratory distress and oxygenation needs.
F. Start a peripheral IV: Starting a peripheral IV is necessary for administering medications and fluids, but it can be done after placing the client on a monitor and starting oxygen therapy.
G. Sputum culture: While obtaining a sputum culture is important for identifying the causative organism of the respiratory infection, it is not as urgent as addressing the client's immediate respiratory distress.
H. NPO: NPO status may be necessary for certain diagnostic tests or procedures, but it does not take priority over addressing the client's respiratory distress and oxygenation needs.
Correct Answer is A
Explanation
A. Ensure that the infant's crib mattress is firm. A firm mattress reduces the risk of SIDS by preventing the infant from sinking into a soft surface, which can obstruct breathing.
B. Prop the infant with a pillow when in a side-lying position. Propping with a pillow is not recommended as it can increase the risk of suffocation and is not a recommended SIDS prevention measure.
C. Place the infant in a prone position whenever possible. Placing an infant in a prone (stomach) position is a significant risk factor for SIDS. Infants should be placed on their backs to sleep.
D. Swaddle the infant in a blanket for sleeping. While swaddling can be safe if done correctly, it is not as critical as ensuring a firm mattress. Additionally, improper swaddling can pose risks if the blanket becomes loose.
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