A patient's data shows the following: Oxygen saturation is 94% on room air, pain is 4 on a scale of 0 to 10, temperature is 99.6°F (37.6°C) orally, and heart rate is 95 beats/minute.
Which physician orders would the nurse anticipate being prescribed after reporting these findings? Select all that apply.
Place client on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
Stat ventilation/perfusion (V/Q) of chest.
Stat 2 views chest x-ray.
Stat Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.
Send sputum for culture & sensitivity.
Correct Answer : A,C,D
The correct answer is choice A, C, and D.
Choice A rationale:
The patient’s oxygen saturation is at 94%, which is just below the normal range of 95-100% for healthy adults breathing room air. Administering oxygen 2 to 4 liters to maintain oxygen saturation at or above 95% is a standard intervention to ensure adequate oxygenation.
Choice B rationale:
A stat ventilation/perfusion (V/Q) scan is typically ordered for suspected pulmonary embolism, which is not indicated by the patient’s current data. The patient’s symptoms do not specifically suggest a V/Q mismatch that would necessitate this diagnostic test.
Choice C rationale:
A chest x-ray is a common diagnostic tool for evaluating the lungs and heart, especially when a patient presents with symptoms that may indicate respiratory or cardiac issues. Given the patient’s temperature and heart rate, which are slightly elevated, a chest x-ray can help identify any potential underlying conditions.
Choice D rationale:
Ordering a CBC, BMP, and blood cultures can help identify the cause of the patient’s fever and tachycardia. These tests provide valuable information about the patient’s immune response, electrolyte balance, kidney function, and whether there is a bacterial infection.
Choice E rationale:
While sending sputum for culture and sensitivity could be helpful if a respiratory infection is suspected, the patient’s data does not strongly indicate a respiratory infection as the primary issue. Therefore, this test may not be the most immediate need.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Reported history of alcoholism.
Choice A rationale:
Employment as a construction worker is not directly relevant to the administration of terbinafine HCL. While it may affect the client’s overall health and risk of injury, it does not impact the medication’s safety or efficacy.
Choice B rationale:
A white blood cell count of 8,500/mm³ (8.5 x 10³/L) is within the normal range and does not indicate any immediate concern that would affect the administration of terbinafine HCL.
Choice C rationale:
Thick and yellow toenails are typical symptoms of a fungal toenail infection and are the reason for prescribing terbinafine HCL. This finding confirms the diagnosis but does not present a contraindication to the medication.
Choice D rationale:
A reported history of alcoholism is crucial to address because terbinafine HCL can cause liver toxicity. Clients with a history of alcoholism are at higher risk for liver damage, and this must be carefully evaluated before starting the medication.
Correct Answer is C
Explanation
Choice A rationale:
Carbon dioxide is primarily eliminated through the lungs, not the kidneys. While the kidneys do play a role in acid-base balance, their primary mechanism for regulating pH is through the excretion or retention of bicarbonate ions (HCO3-), not carbon dioxide itself.
The kidneys' ability to compensate for respiratory acidosis is limited. In cases of severe respiratory acidosis, the kidneys may not be able to adequately compensate, leading to a further decrease in blood pH.
Choice B rationale:
Hyperventilation would actually decrease carbon dioxide levels in the blood, not increase them. Hyperventilation is a state of rapid, deep breathing that leads to increased exhalation of carbon dioxide. This can result in respiratory alkalosis, which is the opposite of respiratory acidosis.
Choice D rationale:
Low blood oxygen levels (hypoxia) can stimulate respiration, but this would not directly cause respiratory acidosis. In fact, hypoxia can sometimes lead to respiratory alkalosis due to hyperventilation.
Respiratory acidosis is primarily caused by impaired carbon dioxide elimination, not decreased oxygen levels.
Choice C rationale:
High levels of carbon dioxide in the blood (hypercapnia) are the hallmark feature of respiratory acidosis. This can occur due to a variety of factors that impair ventilation, such as:
Chronic obstructive pulmonary disease (COPD) Asthma
Pneumonia Sleep apnea
Neuromuscular disorders that affect breathing Drug overdose (e.g., opioids)
The accumulation of carbon dioxide in the blood leads to a decrease in blood pH, which can have a range of negative effects on the body's organ systems.
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