A nurse is caring for a client in the clinic.
The nurse anticipates which of the following orders from the provider based on the suspected diagnosis? (Select all that apply)
IV antibiotics
Urinalysis
Chest x-ray
Chest tube placement
Admit to inpatient
Airborne precautions
Draw an STI lab panel
Complete blood count
Correct Answer : A,C,E,H
The nurse anticipates the following orders from the provider based on the suspected diagnosis:
- A. IV antibiotics: To treat the suspected infection.
- C. Chest x-ray: To assess the lungs for signs of infection, such as pneumonia.
- E. Admit to inpatient: The client's worsening condition and need for aggressive treatment warrant hospitalization.
- H. Complete blood count: To assess the client's overall health status and identify any abnormalities, such as anemia or infection.
Rationale:
- B. Urinalysis: While a urinalysis can be helpful in assessing for urinary tract infections, it is not a priority in this case.
- D. Chest tube placement: This is not indicated unless the client develops a pleural effusion or pneumothorax.
- F. Airborne precautions: This is not necessary for the client's current condition.
- G. Draw an STI lab panel: While this may be relevant for the client's overall health, it is not a priority at this time, especially given the client's acute presentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Fluid overload is not an allergic reaction but rather a complication of transfusion related to the volume of fluid administered, thus diphenhydramine would not be appropriate.
B. Urticaria, or hives, is a common mild allergic reaction that can occur during blood transfusions. Administering diphenhydramine can help prevent or treat this response.
C. Hemolysis is a serious reaction involving the destruction of red blood cells, often due to blood type incompatibility; it is not alleviated by antihistamines.
D. Fever can occur during transfusions but is typically due to non-specific immune reactions and does not respond to diphenhydramine.
Correct Answer is B
Explanation
A. Metabolic acidosis would be indicated by a low pH and a low HCO3, which is not present in this case since HCO3 is normal.
B. The pH of 7.32 indicates acidemia, and a PaCO2 of 50 mmHg suggests respiratory acidosis as the body is retaining carbon dioxide, contributing to the low pH. The HCO3 is normal, indicating that there is no metabolic compensation occurring.
C. Respiratory alkalosis would show a high pH and low PaCO2, which is not the case here.
D. Metabolic alkalosis would present with a high pH and elevated HCO3, which is also not present in these ABG results.
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