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What 2 orders should the nurse complete first?

Chesty

Start oxygen 3 L via nasal cannula

Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3")

Normal saline 150 mi/hour

NPO

Start a IV

Sputum culture

Place the client on a cardiorespiratory monitor

Answer and Explanation

Correct Answer : B,H

A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.

B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.

E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.

H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

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Correct Answer is D

Explanation

A. Ensuring that someone stays with the client for 24 hours is important for immediate postoperative care but does not directly ensure compliance with self-care instructions.
B. Having the client vocalize the instructions ensures that the client understands and can recall the information provided, which is crucial for compliance with self-care. However, it does not provide a point of reference while at home.
C. Speaking clearly and facing the client for lip reading is helpful for communication but does not ensure that the client fully understands and can follow the instructions.
D. Providing written instructions is crucial because written instructions can serve as a reference for the client to review as needed, ensuring they understand and follow the postoperative care procedures, which is essential for preventing complications and promoting healing.

A. Keep head of bed raised 45 degrees. B. Monitor blood glucose level. C. Maintain strict intake and output. D. Assess warmth of extremities.

Correct Answer is B

Explanation

A. Elevating the head of the bed can help improve oxygenation but is not directly related to managing sepsis.
B. Monitoring blood glucose levels is crucial in sepsis management as hyperglycemia can exacerbate the inflammatory response.
C. While intake and output monitoring is important, it is not the priority in the early management of sepsis.
D. Assessing warmth of extremities is important but not the most critical intervention in managing sepsis.

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What 2 orders should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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