A nurse is admitting a client to a medical-surgical unit following a fall at home.
The nurse is discussing the client’s treatment plan with a provider. For each potential provider’s prescription, specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Administer spironolactone
Administer an IV fluid bolus
Obtain an x-ray of the right hip
Administer an iron supplement
Obtain the client’s weight
Administer supplemental oxygen
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}
|
Potential Prescription |
Anticipated |
Nonessential |
Contraindicated |
|
Administer spironolactone |
|
|
✅ |
|
Administer an IV fluid bolus |
✅ |
|
|
|
Obtain an x-ray of the right hip |
✅ |
|
|
|
Administer an iron supplement |
|
✅ |
|
|
Obtain the client’s weight |
✅ |
|
|
|
Administer supplemental oxygen |
|
✅ |
|
Choice A: Administer spironolactone
Spironolactone is a potassium-sparing diuretic used to manage heart failure and hypertension. However, the client’s potassium level is elevated at 5.3 mEq/L (normal range: 3.5 to 5 mEq/L) . Administering spironolactone could exacerbate hyperkalemia, leading to dangerous cardiac arrhythmias. Additionally, the client’s low blood pressure (89/60 mm Hg) and dehydration (indicated by dry skin and tenting) make the use of a diuretic inappropriate as it could further lower blood pressure and worsen dehydration .
Choice B: Administer an IV fluid bolus
The client presents with signs of dehydration (dry skin, tenting, low urine output) and hypotension (BP 89/60 mm Hg). An IV fluid bolus is anticipated to restore intravascular volume, improve blood pressure, and address
dehydration . This intervention is crucial to stabilize the client’s hemodynamic status and improve perfusion to vital organs .
Choice C: Obtain an x-ray of the right hip
The client reports pain in the right hip following a fall, which raises the suspicion of a fracture. An x-ray is essential to diagnose any potential fractures or dislocations, which are common in elderly patients after a fall 5.
Prompt imaging will guide appropriate management and prevent further complications .
Choice D: Administer an iron supplement
While the client has a history of iron-deficiency anemia and is on ferrous sulfate, the immediate need for iron supplementation is nonessential in the context of acute management of the fall and dehydration. The client’s hemoglobin (16 g/dL) and hematocrit (47%) are within normal ranges, indicating that anemia is currently well- managed . The focus should be on stabilizing the client’s acute condition.
Choice E: Obtain the client’s weight
Obtaining the client’s weight is anticipated as it is a critical parameter for calculating medication dosages, fluid requirements, and monitoring the client’s overall health status. Accurate weight measurement is particularly important in elderly patients with multiple comorbidities to ensure precise and safe medical management .
Choice F: Administer supplemental oxygen
The client’s oxygen saturation is 95% on room air, which is within the normal range (95-100%) . Therefore, administering supplemental oxygen is nonessential unless there is evidence of hypoxia or respiratory distress. The primary focus should be on addressing dehydration and hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
The statement “Dark urine” is not typically a manifestation of an allergic reaction to oxacillin. Dark urine can indicate other issues such as dehydration, liver problems, or the presence of blood, but it is not a common sign of an allergic reaction to antibiotics.
Choice B reason:
The statement “Diarrhea” is a common side effect of many antibiotics, including oxacillin, but it is not specifically indicative of an allergic reaction. Diarrhea can occur due to the disruption of normal gut flora by antibiotics, but it does not necessarily mean the patient is allergic to the medication.
Choice C reason:
The statement “Urticaria” (hives) is a classic sign of an allergic reaction. Urticaria presents as raised, itchy welts on the skin and is a common allergic response to medications, including oxacillin. This reaction occurs when the immune system releases histamines in response to the drug.
Choice D reason:
The statement “Fever” can be associated with both infections and allergic reactions, but it is not a definitive sign of an allergic reaction to oxacillin. Fever can occur due to the underlying infection being treated or as a side effect of the medication, but it is not as specific as urticaria for indicating an allergic response.
Correct Answer is D
Explanation
Choice A reason: Diuretic use
Diuretic use can influence the formation of kidney stones, particularly certain types of diuretics that increase calcium excretion in the urine. However, this is not the most common or significant risk factor compared to others like family history or dietary habits. Diuretics such as loop diuretics can increase the risk of calcium stones by increasing calcium excretion.
Choice B reason: BMI less than 25
A BMI less than 25 is generally considered within the normal range and is not typically associated with an increased risk of urolithiasis. In fact, obesity is a more significant risk factor for kidney stones. Higher BMI is linked to increased excretion of stone-forming substances like calcium and oxalate.
Choice C reason: Hypocalcemia
Hypocalcemia, or low calcium levels in the blood, is not a common risk factor for urolithiasis. In fact, low dietary calcium can increase the risk of kidney stones because it leads to higher oxalate absorption in the gut, which can then form stones in the kidneys. Therefore, hypocalcemia is not typically associated with an increased risk of kidney stones.
Choice D reason: Family history
Family history is a significant risk factor for urolithiasis. If a close relative has had kidney stones, the likelihood of developing them increases. This is due to genetic predispositions that affect factors like urine composition and kidney function. Studies have shown that individuals with a family history of kidney stones are more likely to develop them themselves.
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