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 .
Correct Answer : A,D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Brief Introduction This scenario requires applying knowledge of chest tube dynamics and respiratory physiology during patient positioning. Sudden dyspnea in a patient with a hemopneumothorax indicates a potential obstruction in the drainage system, necessitating immediate troubleshooting of the tubing to ensure lung re-expansion and prevent tension pneumothorax or fluid accumulation.
Choice A rationale: Reinforcing the connection with tape is a preventive measure to maintain system integrity. However, it does not address the immediate cause of sudden acute respiratory distress following a position change, which is more likely related to a mechanical obstruction in the tubing rather than a connection failure.
Choice B rationale: Clamping a chest tube is generally contraindicated as it can rapidly lead to a tension pneumothorax by preventing the escape of air and fluid from the pleural space. This action would likely worsen the patient's anxiety and shortness of breath by increasing intrapleural pressure.
Choice C rationale: An occlusive dressing is only applied if the chest tube is accidentally dislodged from the insertion site. Since the scenario implies the tube is still in place but the patient became symptomatic during a turn, applying a dressing over an intact tube is an incorrect intervention.
Choice D rationale: Turning a patient can cause the chest tubing to kink or create dependent loops that trap fluid. This obstruction prevents the drainage of air and blood, leading to sudden respiratory distress. Ensuring the tubing is patent and straight is the immediate priority to restore proper pleural suction.
Correct Answer is ["D","E","F"]
Explanation
Choice A rationale
While it’s important to honor commitments, it’s also crucial to recognize when the caregiving role becomes too stressful or burdensome. Insisting on keeping a promise despite significant stress can lead to caregiver burnout.
Choice B rationale
This statement is not accurate. Moving a loved one into a care facility is sometimes the best decision for both the caregiver and the care recipient. It does not reflect a lack of love, but rather a recognition of the need for professional help.
Choice C rationale
This statement is not accurate. Caring for an adult, especially one with health issues, can be more challenging than raising a child in many ways.
Choice D rationale
Involving the care recipient in the decision-making process can help maintain their autonomy and dignity. It can also make the caregiving process more manageable.
Choice E rationale
It’s normal to have mixed feelings about a loved one for whom you’re providing care. Acknowledging these feelings can be an important step in managing caregiver stress.
Choice F rationale
This statement is not accurate. Setting boundaries is an important part of self-care and can help prevent caregiver burnout.
Choice G rationale
This statement is not accurate. Setting boundaries is an important part of self-care and can help prevent caregiver burnout.
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