The patient is a 49-year-old male who has been experiencing flu-like symptoms, including fever and chest congestion, for 4 days.

He came to the emergency department (ED) last night when his breathing difficulties increased. He has a history of smoking half a pack of cigarettes a day for 20 years.

He has no significant medical or surgical history.

Which two orders should the nurse prioritize?

Chest x-ray

Run 0.9% sodium chloride IV infusion at 150 mL/hour

Sputum culture

Start oxygen 3 L/minute via nasal cannula

Start a peripheral IV

Acetaminophen 350 mg PO every 6 hours for temperature greater than 38.3° C .

Answer and Explanation

Correct Answer : A,B

Choice A rationale
A chest x-ray is a critical diagnostic tool for a patient presenting with flu-like symptoms, fever, chest congestion, and increased breathing difficulties. It can help identify conditions such as pneumonia or other lung diseases, which could be causing the patient’s symptoms.
Choice B rationale
While hydration is important, running a 0.9% sodium chloride IV infusion at 150 mL/hour is not the most immediate need for this patient. The patient’s symptoms are primarily respiratory, and there is no indication of dehydration.
Choice C rationale
A sputum culture could be useful for diagnosing bacterial infections of the respiratory tract. However, it is not the most immediate need for this patient, as the results of a culture test can take time to come back.
Choice D rationale
This is the correct answer. Given the patient’s increased breathing difficulties, starting oxygen therapy can help improve the patient’s oxygen levels and ease their breathing.
Choice E rationale

Starting a peripheral IV might be necessary for administering medications or fluids, but it is not the most immediate need in this scenario.
Choice F rationale
While controlling the patient’s fever is important, it is not as immediate a need as performing a chest x-ray and starting oxygen therapy.

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Correct Answer is D

Explanation

Choice A rationale
Mixing the dextrose in a 50 mL piggyback for a total volume of 100 mL is not the best method for administering the medication. This would dilute the dextrose, potentially reducing its effectiveness.
Choice B rationale
Diluting the dextrose in one liter of 0.9% normal saline solution is not the best method for administering the medication. This would significantly dilute the dextrose, potentially reducing its effectiveness.
Choice C rationale
Asking the pharmacist to add the dextrose to a total parenteral nutrition (TPN) solution is not the best method for administering the medication. This would not provide the immediate glucose boost needed to counteract insulin shock.
Choice D rationale

Pushing the undiluted dextrose slowly through the currently infusing IV is the best method for administering the medication. This allows for rapid administration of a concentrated glucose solution, which is necessary to quickly raise blood glucose levels in a patient experiencing insulin shock.

A. The choice of treatment is best determined by the sensitivity of these genetic markers. B. BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. 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

Choice A rationale
While the sensitivity of genetic markers can influence the choice of treatment, it is not the primary pathophysiological process involved in BRCA1 and BRCA2 genetic testing. The main purpose of these tests is to identify genetic mutations that increase the risk of developing certain types of cancer.
Choice B rationale
BRCA1 and BRCA2 do play a role in protecting mature, functioning breast and ovarian cells. However, this is not the primary reason for conducting BRCA1 and BRCA2 genetic testing. The main purpose of these tests is to identify mutations that increase cancer risk.
Choice C rationale

This is the correct answer. Mutations in BRCA1 or BRCA2 can significantly increase a person’s risk for developing breast and ovarian cancer. Therefore, identifying these mutations through genetic testing can help determine a person’s cancer risk.
Choice D rationale
While inherited mutations in BRCA1 and BRCA2 can influence the prognosis of breast cancer, the primary purpose of BRCA1 and BRCA2 genetic testing is to identify mutations that increase cancer risk, not to determine prognosis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a 50 mL dose of 50% dextrose IV for a patient experiencing insulin shock. What is the best method for administering the medication?

Correct Answer is D

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

The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery. What immediate action should the nurse take?

When formulating a nursing care plan for a client diagnosed with Parkinson’s disease, which nursing problem should be given the highest priority?

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy express that their child wants to continue attending swimming classes. How should the nurse respond?

A caregiver brings a client with end-stage Alzheimer’s disease to the clinic for an appointment with the healthcare provider. The caregiver confides in the nurse about experiencing sleepless nights and frequent bouts of crying. What action should the nurse take?

A patient admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care?

An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? Select all that apply.