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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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Measure and record the client's urinary output every day.
While monitoring urinary output is important, it is not as directly related to the safety concerns associated with the new medications and the client's current state.

B. Obtain a blood pressure reading before the client gets out of bed.
This is the correct answer because both antidepressants and sedatives can cause orthostatic hypotension, which could lead to falls or other complications. Monitoring blood pressure before the client gets up helps to prevent these issues.

C. Obtain the client's vital signs every 4 hours when awake.
Regular vital sign monitoring is important, but specific attention to orthostatic changes is more critical in this scenario.

D. Provide the client with teaching regarding a cardiac diet.
While dietary education is important for long-term health management, it does not address the immediate risk associated with the prescribed medications and potential orthostatic hypotension.

A. Explain that temporary burning at the IV site may occur. B. Apply a topical anesthetic at the infusion site for burning. C. Assess IV site frequently for signs of extravasation. D. Monitor capillary refill distal to the infusion site.

Correct Answer is C

Explanation

A. Explaining that temporary burning at the IV site may occur is important for informing the client about potential side effects but does not address the specific risk associated with vesicant chemotherapeutic agents.

B. Applying a topical anesthetic at the infusion site for burning is not typically indicated during the administration of vesicant chemotherapeutic agents. While it may provide some comfort, it does not address the risk of extravasation.

C. Assessing the IV site frequently for signs of extravasation is essential during the administration of vesicant chemotherapeutic agents. Vesicants can cause tissue necrosis and damage if they leak into surrounding tissues. Early detection of extravasation allows for prompt intervention to minimize tissue damage.

D. Monitoring capillary refill distal to the infusion site is important for assessing peripheral perfusion but does not specifically address the risk of extravasation associated with vesicant chemotherapeutic agents.

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Exhibits Which 2 orders should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client's arm?

Correct Answer is C

Explanation

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Exhibits

Which 2 orders should the nurse complete first?