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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

Explanation

A. This task typically requires a more advanced level of clinical judgment and assessment skills, which are usually beyond the scope of practice for a PN and should be conducted by a Registered Nurse (RN).
B. Removing discontinued peripheral IV catheters is a task that falls within the scope of practice for a Practical Nurse (PN). It does not require the advanced assessment skills or judgment that some other tasks might require.
C. This involves critical thinking and clinical decision-making that are responsibilities typically reserved for an RN, as it requires integrating new information and adjusting care plans based on ongoing assessments.
D. While PNs can perform certain types of wound care, initiating sterile wound care for surgical clients often requires the advanced knowledge and assessment skills of an RN, particularly if the wound care involves evaluating surgical site integrity and potential complications.

A. Remove the transdermal patch until the vomiting subsides. B. Reposition the transdermal patch to the client's trunk. C. Explain that this is a side effect of the medication in the patch. D. Notify the client's healthcare provider of the vomiting.

Correct Answer is D

Explanation

A. Removing the scopolamine patch is not indicated without consulting the healthcare provider.
B. Repositioning the patch is not necessary as it is properly placed for its intended effect.
C. While nausea and vomiting are potential side effects of scopolamine, it's important to notify the healthcare provider to determine the appropriate next steps.
D. Notifying the healthcare provider allows for further evaluation and possible adjustment of the client's postoperative antiemetic regimen.

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What 2 orders should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

Correct Answer is B

Explanation

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

Correct Answer is D

Explanation

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN?

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL (32.2 mmol/L) about preventing complications related to diabetes mellitus. Which statement by the client indicates understanding? Reference Range: Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)?