A nurse is caring for a 43-year-old female client who reports abdominal pain.

Exhibits

For each potential provider's order, click to specify if the potential order is anticipated or contraindicated for this client.

Begin broad spectrum IV antibiotics.

Transfuse 1 unit of packed red blood cells.

Prepare client for endoscopic retrograde cholangiopancreatography.

Administer morphine sulfate IV push for pain.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}

1.   Begin Broad Spectrum IV Antibiotics Anticipated
The client's symptoms, including right upper quadrant pain, nausea, vomiting, jaundice, fever, and elevated white blood cell count, suggest a potential infection or inflammation in the abdominal area, possibly related to the biliary system (e.g., cholecystitis or cholangitis). Broad-spectrum antibiotics are commonly used to treat infections that could be causing these symptoms, especially if the exact pathogen is not yet identified. The elevated white blood cell count further supports the likelihood of an infection.
2.   Transfuse 1 Unit of Packed Red Blood Cells Contraindicated
There is no indication from the provided information that the client has anemia or a significant drop in hemoglobin that would necessitate a blood transfusion. The hemoglobin level is 15.1 g/dL, which is within normal limits. Blood transfusion would typically be considered if there was evidence of significant blood loss or anemia, neither of which is indicated by the client’s current lab results.
3.   Prepare Client for Endoscopic Retrograde Cholangiopancreatography (ERCP) Anticipated
The symptoms described, including right upper quadrant pain radiating to the right shoulder, jaundice, and the dark amber urine, are suggestive of biliary tract involvement, such as gallstones causing obstruction or infection. ERCP is a diagnostic and therapeutic procedure used to visualize and treat conditions of the bile ducts and pancreatic ducts. Given the symptoms and clinical presentation, preparing the client for an ERCP to assess and potentially address issues in the biliary system is appropriate.

4.   Administer Morphine Sulfate IV Push for Pain Contraindicated
The client has a documented allergy to morphine. Administering morphine could lead to an allergic reaction and is therefore contraindicated. Alternative pain management options should be considered, such as non-opioid analgesics or other opioid medications that the client is not allergic to.

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Correct Answer is C

Explanation

A. This is useful for preventing atelectasis in patients who are unable to take deep breaths, but it is not the most critical piece of equipment for this client at this time.
B. While a Hoyer lift may be needed for mobility assistance in the future, it is not the most immediate priority.
C. Guillain-Barre syndrome can rapidly progress, leading to respiratory muscle weakness and the need for mechanical ventilation. Having an intubation tray readily available is crucial to ensure a prompt response if the client's respiratory status deteriorates.
D. A nebulizer is used to deliver medication to the lungs, but it is not the most critical piece of equipment for this client at this time.

A. Spinach B. Anchovies C. Organ meats D. Milk

Correct Answer is A

Explanation

A. Spinach is known to be high in oxalates. Oxalates are compounds that can bind with calcium in the urine, forming calcium oxalate stones, which are the most common type of kidney stones. For clients with a history of kidney stones related to high oxalate intake, it is crucial to limit or avoid high-oxalate foods such as spinach to reduce the risk of further stone formation.
B. Anchovies are not particularly high in oxalates. They are more commonly associated with other nutritional considerations, such as being a good source of omega-3 fatty acids and protein. While anchovies are not a significant source of oxalates, they are not a primary concern for those needing to manage oxalate intake.
C. Organ meats, such as liver and kidneys, are not known for high oxalate content. They are high in other nutrients and substances but do not significantly contribute to oxalate levels in the urine. Therefore, avoiding organ meats is not typically necessary for managing oxalate levels.
D. Milk is not high in oxalates. In fact, dairy products are a good source of calcium, which can help bind oxalates in the gut and reduce their absorption. For individuals managing oxalate levels, increasing calcium intake from dairy products can be beneficial. Milk and other dairy products are generally not restricted in a diet aimed at reducing oxalate intake.

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A nurse is caring for a 43-year-old female client who reports abdominal pain. Exhibits For each potential provider's order, click to specify if the potential order is anticipated or contraindicated for this client.

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A nurse is admitting a client who has Guillain-Barre syndrome. The client complains of an inability to move both legs and reports a tingling sensation above the waistline. Which is the most important piece of equipment for the nurse to keep at this client's bedside?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a 43-year-old female client who reports abdominal pain.

Exhibits

For each potential provider's order, click to specify if the potential order is anticipated or contraindicated for this client.