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Exhibits

Which 2 orders should the nurse complete first?

Acetaminophen 350 mg PO every 6 hours for temperature greater than 101° F (38.3°C)

Place the client on a cardiorespiratory monitor

Start oxygen 3 L/minute via nasal cannula

Chest x ray

Run 0.99% sodium chloride IV infusion at 150 ml/hour

Start a peripheral IV

Sputum culture

Answer and Explanation

Correct Answer : B,C

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.

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Correct Answer is ["A","C","G"]

Explanation

A. Administer oxygen 5 L/minute via simple face mask: Oxygen administration is a priority intervention to improve oxygenation and address the client's low oxygen saturation of 82%.
Hypoxemia can lead to tissue hypoxia and further compromise the client's condition. Therefore, administering oxygen should be the first action taken to ensure an adequate oxygen supply to vital organs.
B. Bacitracin applied topically to lacerations every 12 hours: While wound care is important, administering oxygen and establishing IV access take precedence over topical
treatment. Oxygenation and fluid resuscitation are critical in the immediate management of a trauma patient to ensure adequate tissue perfusion and oxygen delivery.

C. Place 2 large bore peripheral IV's: Establishing IV access is essential for administering medications and fluids rapidly. This is particularly important in this scenario where the client may require immediate fluid resuscitation due to hypotension (blood pressure of 83/41 mm Hg).
Large bore IV access allows for rapid infusion of fluids and medications to stabilize the client's hemodynamic status.

D. X-ray of the right arm and cervical spine: While diagnostic imaging is important for assessing injuries, it is not as urgent as administering oxygen and establishing IV access. Oxygenation and fluid resuscitation are higher priorities to stabilize the client's condition before proceeding with diagnostic tests.

E. Computed tomography scan of the brain: While a CT scan of the brain is essential for assessing potential head injuries, the immediate focus should be on stabilizing the client's oxygenation and hemodynamic status. Administering oxygen and fluids take precedence over diagnostic imaging to address the client's hypoxemia and hypotension.

F. Vital signs every 1 hour: Monitoring vital signs is important for ongoing assessment, but it is not as urgent as administering oxygen and fluids. Vital signs should be monitored closely, but immediate interventions to address hypoxemia and hypovolemia are critical to stabilize the client's condition.

G. Give 1 Liter bolus of 0.9% sodium chloride solution IV once: The client's hypotension (blood pressure of 83/41 mm Hg) indicates hypovolemia and the need for fluid resuscitation. Administering a bolus of intravenous fluids (1 Liter bolus of 0.9% sodium chloride solution) is essential to address hypovolemia and improve perfusion to vital organs. This intervention helps stabilize the client's blood pressure and prevent further deterioration of her condition.

A. BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. B. The choice of treatment is best determined by the sensitivity of these genetic markers. C. Mutations in BRCA1 or BRCA2 identify a client's risk for cancerous cell development in breast tissue. D. The prognosis of breast cancer is most successful when these markers are inherited mutations.

Correct Answer is C

Explanation

A. BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. This is not accurate; BRCA1 and BRCA2 genes are involved in DNA repair, and mutations in these genes increase cancer risk.
B. The choice of treatment is best determined by the sensitivity of these genetic markers. While genetic markers can influence treatment decisions, this option does not directly address the role of BRCA1 and BRCA2 mutations in cancer risk.
C. Mutations in BRCA1 or BRCA2 identify a client's risk for cancerous cell development in breast tissue. This is correct. Mutations in these genes significantly increase the risk of developing breast and ovarian cancer.
D. The prognosis of breast cancer is most successful when these markers are inherited mutations.
This statement is incorrect. The presence of BRCA1 or BRCA2 mutations influences risk, not necessarily prognosis or treatment success.

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Exhibits Which 2 orders should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","G"]

Explanation

The nurse is preparing a client with breast cancer for BRCA1 and BRCA2 genetic testing. Which pathophysiological process should the nurse use to support client teaching?

Correct Answer is C

Explanation

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Exhibits

Which 2 orders should the nurse complete first?