Questions 42

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Female Reproductive System NCLEX RN Questions Questions

Extract:

The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is caring for a 70-year-old client.
Item 1 of 1
Nurses' Notes
1100: Client was brought into the ED via emergency medical services (EMS) after he was found wandering the streets and completely disoriented. He was carrying a wallet and identification. His previous medical history was obtained from medical records—history of atrial fibrillation and diabetes mellitus (type two). On assessment, the client is lethargic, disoriented, and mumbling incoherent words. Breathing appears slightly labored, and wheezes with scattered rhonchi are noted in the bilateral lung fields—productive cough with a large amount of mucous. Skin is hot to touch, pale in tone; pulses 2+ and irregular. The client has an unkempt appearance and is malodorous. Peripheral venous access device (VAD) placed in right forearm. Vital signs: T 102° F (38.9° C), P 92, RR 24, BP 144/89, pulse oximetry reading 91% on room air. Orders received from the physician.


Question 1 of 5

The nurse reviews the physician's orders and plans implementation. For each potential nursing action, click to specify whether the action is a high priority or a low priority.

Nursing Actions High priority
Educate the client on using the incentive spirometer
Perform a head-to-toe skin assessment
Notify radiology to obtain the portable chest radiograph (x-ray)
Administer albuterol via nebulizer
Apply supplemental oxygen via nasal cannula
Collect ordered laboratory work (CBC, CMP, blood cultures)
Perform admission medication reconciliation

Correct Answer: C, D, E, F (high priority); A, B, G (low priority)

Rationale: High priority: Chest x-ray, albuterol, oxygen, and labs address acute respiratory distress and infection. Low priority: Spirometer education, skin assessment, and medication reconciliation can be delayed.

Extract:


Question 2 of 5

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Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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