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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

Explanation

A. Leave the room and close the door quietly. Respecting the client's privacy is essential. The nurse should leave the room quietly and return later to administer the medication.
B. Ignore the behavior and hang the IV antibiotic. Ignoring the behavior and proceeding with the medication administration would violate the client's privacy.
C. Complete an unusual occurrence report. This situation does not require an incident report; it is a private matter between the client and the visitor.
D. Tell the client to stop the inappropriate behavior. The behavior is not necessarily inappropriate within the context of the client's rights to privacy and intimacy.

A. Bruising of the skin. B. Low-grade fever. C. Abdominal cramping. D. Bloody emesis.

Correct Answer is D

Explanation

A. Bruising of the skin is not typically associated with acute gastritis caused by contaminated water. While bruising may be a sign of other medical conditions or complications, it is not directly related to gastritis.

B. Low-grade fever can be a symptom of gastritis, especially if it is caused by an infectious agent. However, it is not typically a severe or emergent symptom that requires immediate reporting unless it is accompanied by other concerning symptoms.

C. Abdominal cramping is a common symptom of gastritis and may occur due to inflammation of the stomach lining. While it should be monitored, it is not as concerning as the potential complication indicated by option D.

D. Bloody emesis (vomiting blood) is a serious symptom that can indicate severe gastritis or complications such as gastrointestinal bleeding. It is essential to report this symptom promptly as it may require immediate medical attention and intervention.

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Exhibits Which 2 orders should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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Exhibits

Which 2 orders should the nurse complete first?