A nurse is caring for an adult client who has a fever of 39.4°C (103°F) and is receiving 0.9% sodium chloride IV at 125 mL/hr. Over the last hour, the nurse notes that the client's urine output is 20 mL. The nurse should report this finding to the provider and anticipate a prescription for what?
An antipyretic medication
A diuretic medication
A blood culture
A fluid bolus
The Correct Answer is D
Choice A reason: An antipyretic medication is not the best answer because it does not address the client's low urine output. An antipyretic medication is a drug that lowers the body temperature by reducing the production of heat or increasing the loss of heat. It may help the client feel more comfortable, but it does not improve the kidney function or prevent dehydration.
Choice B reason: A diuretic medication is not the best answer because it may worsen the client's low urine output. A diuretic medication is a drug that increases the excretion of water and electrolytes by the kidneys. It may lower the blood pressure and reduce the fluid overload, but it may also cause dehydration, electrolyte imbalance, and kidney damage.
Choice C reason: A blood culture is not the best answer because it does not address the client's low urine output. A blood culture is a laboratory test that detects the presence of bacteria or other microorganisms in the blood. It may help identify the cause of the fever and guide the antibiotic therapy, but it does not improve the kidney function or prevent dehydration.
Choice D reason: A fluid bolus is the best answer because it may improve the client's low urine output. A fluid bolus is a rapid infusion of a large volume of fluid, usually isotonic saline or lactated Ringer's solution. It may increase the blood volume and pressure, improve the tissue perfusion, and stimulate the urine production. It may also help lower the fever by diluting the pyrogens and increasing the heat loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Sudden abdominal pain is a sign of gastrointestinal perforation, which is a life-threatening complication of peptic ulcer disease. It occurs when the ulcer erodes through the wall of the stomach or duodenum, causing leakage of gastric contents into the peritoneal cavity. This causes inflammation, infection, and peritonitis.
Choice B reason: Hyperactive bowel sounds are not indicative of gastrointestinal perforation. They may be present in other conditions, such as gastroenteritis, intestinal obstruction, or diarrhea.
Choice C reason: Bradycardia is not indicative of gastrointestinal perforation. It may be caused by other factors, such as vagal stimulation, medication side effects, or cardiac disorders.
Choice D reason: Decreased blood pressure is not indicative of gastrointestinal perforation. It may be a result of other causes, such as hypovolemia, shock, or dehydration.
Correct Answer is A
Explanation
Choice A reason: Fried chicken is a food that the nurse should tell the client to avoid eating. Fried chicken is high in fat, which can trigger or worsen the symptoms of GERD. Fat can relax the lower esophageal sphincter, which is the muscle that prevents the stomach acid from flowing back into the esophagus. Fat can also delay the stomach emptying, which can increase the pressure and acid production in the stomach.
Choice B reason: Nonfat milk is not a food that the nurse should tell the client to avoid eating. Nonfat milk is low in fat, which can help prevent or reduce the symptoms of GERD. Nonfat milk can also provide calcium and protein, which are essential nutrients for the client's health.
Choice C reason: Bananas are not a food that the nurse should tell the client to avoid eating. Bananas are low in acid, which can help neutralize the stomach acid and soothe the esophagus. Bananas are also rich in fiber, which can promote digestion and prevent constipation.
Choice D reason: Oatmeal is not a food that the nurse should tell the client to avoid eating. Oatmeal is a whole grain that is low in fat and high in fiber, which can help prevent or reduce the symptoms of GERD. Oatmeal can also absorb the excess acid in the stomach and prevent it from refluxing into the esophagus.
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