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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 ["B","C","G","H"]

Explanation

A. While addressing anxiety is important, it is not the most immediate priority in the emergency setting where acute pain, potential infection, and fluid management take precedence.
B. Given the diagnosis of appendicitis, preventing infection is crucial. The client is at risk for developing an infection or sepsis if the appendix perforates, which could result in peritonitis.
C. The client is experiencing severe abdominal pain (pain rating of 9/10). Effective pain management is essential for the client’s comfort and stabilization.
D. This is more relevant post-surgery. In the emergency department, the focus should be on stabilizing the client and preparing her for surgery.
E. The client has regular bowel movements and this is not a priority in the context of acute appendicitis.
F. This is a consideration for longer-term inpatient care or post-surgery, not an immediate priority in the emergency setting.
G. The client is receiving a bolus of Lactated Ringer’s to manage her fluid volume.

Maintaining adequate hydration and correcting any potential dehydration or fluid imbalance is vital.
H. Educating the client about her diagnosis and the plan of care, including the upcoming surgery, helps reduce anxiety and ensures that she is informed about her treatment.

Correct Answer is ["22"]

Explanation

To calculate the drip rate for an IV, you can use the formula: (Volume to be infused (mL) x Drop factor (gtt/mL)) / Time (min). For the prescribed 1 unit of PRBC at 350 mL to be infused over 4 hours with a drop factor of 15 gtt/mL, the calculation would be: (350 mL x 15 gtt/mL) / (4 hours x 60 minutes/hour). This simplifies to (5250 gtt) / (240 min), which equals 21.875 gtt/min. When rounded to the nearest whole number, the nurse should regulate the infusion to 22 gtt/min.

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What 2 orders should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits What goal(s) should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply.

Correct Answer is ["B","C","G","H"]

Explanation

The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)

Correct Answer is ["22"]

Explanation

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