A nurse is caring for a male client who reports abdominal pain.

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

Change IV fluids to 0.9 % sodium chloride with 20 KCL @ 125 mL/hr.

CT of the abdomen with contrast.

Type and cross match blood.

Administer ampicillin/sulbactam IV bolus.

Request a diet high in fiber

Answer and Explanation

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

Order 1: Change IV fluids to 0.9% sodium chloride with 20 KCl @ 125 mL/hr.

Anticipated: The client has hypokalemia (K+ decreased to 3.2 mEq/L on Day 2), which requires correction to prevent complications like cardiac arrhythmias. Adding potassium chloride (KCl) to the IV fluids and increasing the infusion rate addresses dehydration and electrolyte imbalance.

Order 2: CT of the abdomen with contrast.

Contraindicated: The client has elevated creatinine levels on Day 1 (1.1 mg/dL, borderline for kidney function). Although it improved by Day 2 (0.9 mg/dL), administering IV contrast can still pose a risk of nephrotoxicity, particularly in a patient with potential dehydration and borderline renal function. An abdominal CT scan without contrast is preferred in this situation.

Order 3: Type and crossmatch blood.

Anticipated: The client's hemoglobin and hematocrit are significantly decreased (Hb dropped from 12 g/dL to 11 g/dL, and Hct from 37% to 30%), indicating possible ongoing blood loss (positive stool occult blood and worsening anemia). Typing and crossmatching blood prepare for a transfusion if necessary.

Order 4: Administer ampicillin/sulbactam IV bolus.

Contraindicated: The client has a documented allergy to penicillin, and ampicillin/sulbactam is a penicillin-class antibiotic. Administering it could trigger an allergic reaction.

Order 5: Request a diet high in fiber.

Contraindicated: A high-fiber diet is contraindicated in acute diverticulitis due to the risk of worsening intestinal irritation and obstruction. The client is also currently NPO due to nausea, vomiting, and suspected complications.

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Correct Answer is D

Explanation

A. "Do you have a history of chronic alcohol abuse?": Chronic alcohol abuse is not a direct risk factor for Guillain-Barré syndrome.

B. "Are you taking a multivitamin?": This question is not relevant to the etiology of Guillain-Barré syndrome.

C. "Have you traveled overseas recently?": Travel history is more relevant for infectious diseases but not specifically for Guillain-Barré syndrome.

D. "Have you had a recent viral infection?": Guillain-Barré syndrome often follows a recent viral or bacterial infection, such as respiratory or gastrointestinal illness.

A. Measure the circumference of the thigh. B. Instruct the client to wiggle their toes. C. Palpate the femoral pulse. D. Monitor the client's calf for edema.

Correct Answer is B

Explanation

A. Measure the circumference of the thigh: While this can assess swelling, it does not directly evaluate neurovascular status.

B. Instruct the client to wiggle their toes: Movement of the toes assesses motor function and indicates intact neurovascular status.

C. Palpate the femoral pulse: Palpating the femoral pulse does not specifically evaluate distal circulation or nerve function.

D. Monitor the client's calf for edema: Edema may suggest circulation issues but is not a comprehensive neurovascular assessment.

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A nurse is caring for a male client who reports abdominal pain. Exhibits For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

Correct Answer is D

Explanation

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Correct Answer is B

Explanation

A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

A nurse is preparing to administer total parental nutrition (TPN) 1800 mL to infuse over 24 hr. The nurse should set the IV pump to deliver ha many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

A nurse is planning care for a client who has cirrhosis of the liver. Which of the following actions should the nurse include in the plan? (Select all that apply.)

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition?

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

A nurse is caring for a male client who reports abdominal pain.

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