The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.
Complete the following sentence by using the lists of options.
The nurse should first address the client's
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
- Lung sounds: The client is exhibiting slight inspiratory wheezes, suggesting airway narrowing that could worsen quickly, particularly with a history of asthma. Following the ABC priority framework (Airway, Breathing, Circulation), any compromise in breathing must be assessed and managed first to prevent respiratory decline.
- Bowel sounds: Although bowel sounds are hyperactive, they do not immediately threaten life or stability. They are typically monitored rather than prioritized unless accompanied by severe gastrointestinal symptoms like obstruction.
- Heart rate: Tachycardia is present but mild at 104/min and not currently associated with hypotension or hypoxia. While important to monitor, it is a secondary concern after ensuring airway patency and addressing breathing issues.
- Anxiety: Anxiety may be contributing to elevated heart rate and hyperactive bowel sounds but does not represent an immediate physiological risk. Emotional support is important but should be provided after stabilizing airway and circulation.
- Vaginal spotting: Vaginal spotting, especially in early pregnancy with abdominal tenderness, raises concern for ectopic pregnancy. After securing the airway, the next concern would be assessing for ongoing or worsening vaginal bleeding, which could signify internal hemorrhage.
- Hemoglobin: The client's hemoglobin is low-normal (11 g/dL), suggesting mild anemia, possibly from chronic or early bleeding. However, there are no signs of active major blood loss requiring emergent correction, so it would not take immediate precedence over bleeding evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will use animal skin condoms when having sex.": Animal skin condoms do not provide reliable protection against HIV transmission because they have small pores that can allow viruses to pass through. Latex or synthetic condoms are recommended for effective protection.
B. "I will put soiled dressings in a tied plastic bag before placing them in the trash.": Properly disposing of soiled dressings in a securely tied plastic bag helps prevent the spread of infectious material and minimizes the risk of exposure to others, reflecting good infection control practices at home.
C. "I will place used sharp items in an empty cereal box for disposal.": Sharps should be disposed of in a puncture-resistant, labeled sharps container. An empty cereal box is not puncture-proof and can easily be breached, posing a significant risk for needlestick injuries.
D. "I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water.": The correct disinfection solution for HIV is a mixture of one part bleach to 10 parts water, not peroxide. Using an incorrect disinfectant reduces the effectiveness of killing the virus on surfaces.
Correct Answer is B
Explanation
A. Medication: The medication, erythromycin, is clearly stated and appropriately spelled. There is no confusion about what drug the provider intended to prescribe, so there is no immediate need to clarify the medication name itself.
B. Route: The prescription does not specify the route of administration, which is essential for safe medication delivery. Erythromycin can be given orally or intravenously, and using the wrong route could lead to serious complications. Clarifying the route ensures proper technique and absorption.
C. Dosage: The dosage of 500 mg is within the standard therapeutic range for erythromycin, depending on the severity and type of infection. Since the dose appears appropriate, it does not require immediate clarification unless clinical concerns arise.
D. Time: Although "four times per day" is broad, it is generally understood as approximately every six hours. While more exact times can improve consistency, missing the route of administration is a more critical and urgent issue to clarify for client safety.
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