A nurse in the emergency department (ED) is caring for an older adult client.
Which of the following prescriptions from the provider should the nurse anticipate? Select all that apply.
Obtain a serum WBC count.
Insert indwelling urinary catheter.
Make the client NPO.
Initiate antibiotic therapy.
Obtain a consent for surgery.
Withhold metoprolol.
Administer acetaminophen.
Collect urine for urinalysis and culture and sensitivity.
Obtain chest x-ray.
Correct Answer : A,D,G,H
A. Obtain a serum WBC count: A WBC count will help assess for infection, as the client presents with fever, confusion, and urinary symptoms. Elevated WBC could suggest a urinary tract infection (UTI) or other infection.
B. Insert indwelling urinary catheter: An indwelling catheter is not immediately necessary unless the client is unable to void or requires continuous monitoring. Non-invasive methods like obtaining a urine sample for analysis would be a priority.
C. Make the client NPO: There is no indication that the client requires NPO status at this time. Unless surgery or another procedure is planned, this is not necessary.
D. Initiate antibiotic therapy: Given the client's symptoms (fever, confusion, urinary frequency, urgency, and dark urine), a UTI or other infection is likely. Antibiotics are needed to treat the suspected infection.
E. Obtain a consent for surgery: There is no indication that surgery is needed based on the current clinical information. The primary concern is infection, not surgical intervention.
F. Withhold metoprolol: While metoprolol may lower blood pressure, there is no indication to withhold it at this time. The client’s blood pressure is already low, and withholding this medication could worsen hypotension. Any changes in the medication regimen should be made based on further evaluation by the provider.
G. Administer acetaminophen: Acetaminophen is indicated to help reduce the client's fever (39.3°C/102.7°F). Managing the fever will help improve comfort and prevent complications like delirium.
H. Collect urine for urinalysis and culture and sensitivity: Urine analysis and culture will help confirm the presence of a UTI, identify the causative pathogen, and guide appropriate antibiotic therapy.
I. Obtain chest x-ray: A chest x-ray is not necessary unless there is a suspicion of a respiratory infection, such as pneumonia. The symptoms are more consistent with a UTI or systemic infection, so a chest x-ray is not a priority.
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Related Questions
Correct Answer is C
Explanation
A. Assessing IV patency is important but comes after confirming the client is not allergic.
B. Checking compatibility ensures safe administration but is not the first priority.
C. Reviewing the client's allergy history is the priority to prevent a potentially life-threatening allergic reaction.
D. Obtaining the medication is necessary but only after confirming it is safe for the client.
Correct Answer is ["A","C","D","E"]
Explanation
A. Place the client in an upright position leaning over a bedside table – This position allows for optimal access to the pleural space and facilitates gravity-assisted drainage of pleural fluid.
B. Inform the client they will be sedated for the procedure – Thoracentesis is typically performed under local anesthesia, not sedation, unless the client has specific complications or needs.
C. Obtain informed consent from the client – Thoracentesis is an invasive procedure, and informed consent is required to ensure the client understands the risks, benefits, and alternatives.
D. Explain that a needle will be inserted in the pleural space to withdraw fluid – Providing a clear explanation of the procedure helps reduce anxiety and ensures the client understands what to expect.
E. Administer a cough suppressant to the client prior to the procedure – A cough suppressant can help prevent the client from coughing during the procedure, reducing the risk of complications such as needle displacement or injury.
F. Inform the client that they will need to fast 4 hr prior to the procedure – Fasting is not required for a thoracentesis. This procedure is usually performed with the client awake and does not involve general anesthesia.
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