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    RN Comprehensive Predictor 2023 Proctored Exam
    Select All That Apply

    A nurse is caring for a client in the emergency department. Exhibits Select the 4 interventions nurse should take.

    Explanation & Rationale

    A. Instruct the client on the use of an incentive spirometer. Although this intervention can improve lung expansion, it is not a priority in this situation, given the possibility of an airborne infectious disease and the need to address systemic and diagnostic concerns first. B. Request a glucocorticoid prescription from the provider. While glucocorticoids may reduce inflammation, there is no immediate indication they are necessary based on the client's presentation. The priority is diagnosing and managing the underlying infection. C. Obtain blood cultures. Blood cultures are critical to identify any systemic infection that may be contributing to the client's fever, tachycardia, and worsening symptoms. This helps guide the initiation of appropriate antimicrobial therapy. D. Obtain a sputum culture. The client’s productive cough with blood, fever, and weight loss raise suspicion for serious respiratory infections, such as tuberculosis (TB) or other pathogens. A sputum culture is necessary to identify the causative organism for targeted treatment. E. Recommend ABGs be drawn. The client’s oxygen saturation has dropped to 92% on room air, and there is an increase in respiratory rate, indicating possible hypoxemia or impaired gas exchange. Arterial blood gases (ABGs) provide critical information about oxygenation, ventilation, and acid-base status, guiding further interventions. F. Place the client in a negative-pressure room. The symptoms, including a cough producing blood-tinged sputum, fever, and weight loss, are consistent with a potential diagnosis of TB or another airborne infectious disease. A negative-pressure room prevents the spread of airborne pathogens to others. G. Administer small, frequent meals. Although the client reports a lack of appetite and weight loss, this intervention is not urgent. Addressing the client’s infection and respiratory status takes precedence.

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