As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.
Which interventions should you perform?
Check capillary refill on bilateral upper extremities.
Administer morphine 2 mg IV as ordered.
Perform range of motion exercises.
Administer ondansetron 4 mg IV as ordered.
Correct Answer : A,B,D
D.
Choice A rationale
Checking capillary refill on bilateral upper extremities can help assess peripheral circulation and identify any potential vascular injuries.
Choice B rationale
Administering morphine 2 mg IV as ordered would help manage the patient’s pain.
Choice C rationale
Performing range of motion exercises may not be appropriate immediately after the fall and before the extent of the patient’s injuries are fully assessed.
Choice D rationale
Administering ondansetron 4 mg IV as ordered can help manage any nausea or vomiting that the patient may experience, which can be a side effect of the morphine or a result of the fall itself. TemazepamTemazepam Explore
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Buttered whole wheat toast and coffee are not the best options for a patient with diarrhea. Whole wheat toast is high in fiber, which can exacerbate diarrhea. Coffee is a diuretic and can lead to further dehydration, which is a risk with diarrhea.
Choice B rationale
Granola is high in fiber and can worsen diarrhea. Strawberries, while a good source of vitamins, are also high in fiber. Tea can be dehydrating, which is not ideal when dealing with diarrhea.
Choice C rationale
Oatmeal is a bland and easily digestible food that can help to firm up the stool. Bananas are a good source of potassium and can help replace electrolytes that may be lost through diarrhea. Herbal tea is a non-caffeinated option that can help to soothe the digestive system.
Choice D rationale
Sausage is high in fat, which can worsen diarrhea. Eggs, while a good source of protein, can be hard to digest for some people and may not be the best choice during a bout of diarrhea. Milk is a common allergen and can cause digestive issues in people who are lactose intolerant.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"}}
Explanation
Based on the questionand the known effects of furosemide, here’s how each assessment finding can be categorized:
- Potassium 3.1 mEq/L: This is anon-therapeutic side effect.Furosemide is a diuretic that increases the excretion of water, sodium, and potassium from the body.This can lead to hypokalemia, or low potassium levels.
- Prothrombin time/INR 2.2: This is likely anunrelated finding.Furosemide does not typically affect prothrombin time or INR.However, the patient is also taking warfarin, which is an anticoagulant known to increase INR.
- Urine output: 600 mL: This is atherapeutic result.Furosemide works by increasing the amount of urine the body makes, which helps reduce swelling and symptoms of fluid retention.
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