A nurse is caring for an adolescent in an emergency department.

Vital Signs.

2300: Medical History.

Blood pressure 120/78 mm Hg. Apical pulse rate 100/min.

Respiratory rate 20/min.

2400: Temperature 37.9° C (100.2° F). Oxygen saturation 98% on room air.

Nurses' Notes.

Blood pressure 112/64 mm Hg. Apical pulse rate 108/min.

Respiratory rate 28/min.

Temperature 38.9° C (102° F). Oxygen saturation 95% on room air.

Medical History.

History of rheumatic fever with resulting cardiac valve damage.

Nurses' Notes.

2300: Adolescent brought to emergency department by their parent.

Adolescent reports intermittent low-grade fever and anorexia.

Manifestations presented a few days after having dental work performed.

Now they are worse.

Adolescent noticed shortness of breath with exertion today.

Adolescent in semi-reclining position.

Respirations easy and unlabored while at rest.

Mild dyspnea observed when adolescent ambulated to the room.

Lung sounds clear bilaterally.

Oral mucous membranes pink with petechiae noted.

Adolescent reports diffuse joint pain as 2 on a scale of 0 to 10. 2400: Adolescent restless and sweating, sitting in high-Fowler's position.

Dyspnea noted at rest.

Adolescent reports pain in mid-chest as dull, aching, and as 2 on a scale of 0 to 10. Few coarse rales auscultated bilaterally.

The nurse reports the 2400 assessment findings to the provider.

Which of the following should the nurse anticipate the provider will prescribe? For each potential provider's prescription, specify if the potential prescription is anticipated or contraindicated for the client.

Obtain blood cultures x 3.

Administer antibiotic therapy.

Obtain an echocardiogram.

Restrict dental hygiene.

Perform strenuous exercise regimen twice daily.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale:

Obtaining blood cultures x 3 is anticipated for the client. This is because the adolescent’s symptoms such as fever, shortness of breath, and petechiae could indicate a bacterial infection, possibly endocarditis, which is a risk for individuals with a history of rheumatic fever and cardiac valve damage. Blood cultures would help identify the causative bacteria.

Choice B rationale:

Administering antibiotic therapy is anticipated for the client. The adolescent’s symptoms suggest a possible bacterial infection, which could have been introduced during the recent dental work. Antibiotics would help eliminate the bacteria and prevent further complications.

Choice C rationale:

Obtaining an echocardiogram is anticipated for the client. Given the adolescent’s history of rheumatic fever and cardiac valve damage, and current symptoms like shortness of breath and chest pain, an echocardiogram would help assess the condition of the heart valves and detect any abnormalities.

Choice D rationale:

Restricting dental hygiene is contraindicated for the client. Good oral hygiene is important, especially for individuals with a history of rheumatic fever and cardiac valve damage, as it helps prevent oral infections that could potentially spread to the heart.

Choice E rationale:

Performing a strenuous exercise regimen twice daily is contraindicated for the client. The adolescent is currently experiencing symptoms like shortness of breath and chest pain, which could be exacerbated by strenuous exercise. It’s important to avoid overexertion until the adolescent’s condition stabilizes.

So, the correct answer is, after analyzing all choices, Choices A, B, and C are anticipated for the client, while Choices D and E are contraindicated. .

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Correct Answer is B

Explanation

Choice A rationale:

A brief episode of ventricular tachycardia, or a rapid heart rate, can occur in patients receiving thrombolytic therapy. However, it is not typically a reason to stop the drug infusion.

Choice B rationale:

Bleeding from the gums can be a sign of excessive bleeding, which is a major risk of thrombolytic therapy. This would be a reason to stop the drug infusion.

Choice C rationale:

A decreased level of consciousness can have many causes and is not specifically associated with thrombolytic therapy.

Choice D rationale:

An increase in blood pressure is not typically a reason to stop thrombolytic therapy.

So, the correct answer is B, after analyzing all choices.

A. Temperature. B. Oxygen saturation. C. Blood pressure. D. Weight. E. Urine output. F. Breath sounds.

Correct Answer is ["B","C","D","F"]

Explanation

Choice A rationale:

The client’s temperature decreased from 37.6°C to 36.8°C1. This is within the normal body temperature range of 36.5°C to 37.2°C2, so it does not require further action.

Choice B rationale:

The client’s oxygen saturation decreased from 95% to 88%1. Normal pulse oximetry values are typically above 95%2. This decrease could indicate that the client is not getting enough oxygen, which requires further action.

Choice C rationale:

The client’s blood pressure increased from 108/50 mm Hg to 138/80 mm Hg. Normal blood pressure for adults is below 120/80 mm Hg. This increase could indicate worsening heart failure, which requires further action.

Choice D rationale:

The client’s weight increased from 80 kg to 82.1 kg. Rapid weight gain may be a sign of fluid retention, a common symptom of heart failure. This requires further action.

Choice E rationale:

The client’s urine output decreased from 480 mL/8 hr to 320 mL/8 hr.However it is still above 30ml/hr signifying normal renal function

Choice F rationale:

On Day 4, the client’s breath sounds were scattered, and crackles were heard bilaterally. This could indicate fluid accumulation in the lungs, a common symptom of heart failure. This requires further action.

So, the correct answer is Choices B, C, D, and F, after analyzing all choices.

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Naxlex Comprehensive Predictor Exams

The nurse is administering a thrombolytic agent to a patient having an acute myocardial infarction. Which patient data indicates that the nurse should stop the drug infusion?.

Correct Answer is B

Explanation

Correct Answer is ["B","C","D","F"]

Explanation

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