Nokea
The nurse is caring for a patient with pneumonia has a fever of 38.4 C (101.1 F). Which of the following orders should the nurse implement first?
- A. Administer acetaminophen 650 mg.
- B. Obtain blood and sputum cultures.
- C. Administer ceftriaxone 1 g IV.
- D. Give patient cool compresses.
Correct Answer: B
Rationale: Obtaining cultures before antibiotic administration is critical to identify the causative organism and ensure appropriate treatment. Administering acetaminophen and ceftriaxone are important but should follow culture collection to avoid altering results. Cool compresses are a supportive measure but not the priority.
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After the nurse has received change-of-shift report about the following four patients, which patient should be assessed first?
- A. A 7-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
- B. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
- C. A 46-year-old patient who has a deep vein thrombosis and is complaining of sudden onset shortness of breath
- D. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 37.9 C (100.2 F)
Correct Answer: C
Rationale: Sudden onset shortness of breath in a patient with a deep vein thrombosis suggests a pulmonary embolism and requires immediate assessment and actions such as oxygen administration. The other patients also should be assessed as soon as possible, but there is no indication that they may need immediate action to prevent clinical deterioration.
The nurse is caring for a patient who has a steering wheel injury as a result of an automobile accident. Which of the following findings should be of most concern to the nurse during the initial assessment?
- A. Paradoxical chest movement
- B. The complaint of chest wall pain
- C. A heart rate of 110 beats/minute
- D. A large bruised area on the chest
Correct Answer: A
Rationale: Paradoxical chest movement indicates that the patient may have flail chest, which can severely compromise gas exchange and can rapidly lead to hypoxemia. Chest wall pain, a slightly elevated pulse rate, and chest bruising all require further assessment or intervention, but the priority concern is poor gas exchange.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which of the following information best supports this diagnosis?
- A. Weak, nonproductive cough effort
- B. Large amounts of greenish sputum
- C. Respiratory rate of 28 breaths/minute
- D. Resting pulse oximetry (SPO2) of 85%
Correct Answer: A
Rationale: The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
The nurse notes new onset confusion in an older-adult patient in a long-term care facility. The patient is normally alert and oriented. In which order should the nurse take the following actions?
- A. Obtain the oxygen saturation.
- B. Check the patient's pulse rate.
- C. Document the change in status.
- D. Notify the health care provider.
Correct Answer: A,B,D,C
Rationale: Assessment for physiological causes of new onset confusion such as pneumonia, infection, or perfusion problems should be the first action by the nurse. Airway and oxygenation should be assessed first, then circulation. After assessing the patient, the nurse should notify the health care provider. Finally, documentation of the assessments and care should be done.
Which of the following prescriptions should the nurse implement first for a patient who has just been admitted with probable bacterial pneumonia and sepsis?
- A. Administer Aspirin suppository.
- B. Send to radiology for chest x-ray.
- C. Give ciprofloxacin 400 mg IV.
- D. Obtain blood cultures from two sites.
Correct Answer: D
Rationale: Initiating antibiotic therapy rapidly is essential, but it is important that the cultures be obtained before antibiotic administration. The chest radiograph and Aspirin administration can be done last.