Exhibits

Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?

Give a bolus of 1,000 mL 0.9% sodium chloride

Repeat blood gas in 1 hour

Place the client in a prone position

Perform endotracheal suctioning

Chest x-ray now

Administer inhaled corticosteroid

Answer and Explanation

Correct Answer : B,C,D

A. Giving a bolus of 1,000 mL 0.9% sodium chloride is typically used to treat hypovolemia or electrolyte imbalances, which are not indicated by the patient's current lab values or clinical
situation.
B. Repeating the blood gas in 1 hour is a reasonable order as it would provide information on whether the patient's respiratory status is improving following interventions for ventilator-associated pneumonia.
C. Placing the client in a prone position can improve oxygenation in patients with respiratory distress by redistributing lung perfusion, making it a suitable intervention for this patient with diminished breath sounds and crackles.
D. Performing endotracheal suctioning would help clear secretions, which may be contributing to the patient's diminished breath sounds and crackles, and is consistent with the care for a patient with pneumonia.
E. A chest x-ray now would typically be ordered if there was a suspicion of a new onset condition such as a pneumothorax or pleural effusion, which is not indicated by the patient's current presentation.
F. Administering an inhaled corticosteroid is generally used for long-term management of chronic respiratory conditions and is not typically used for acute management of ventilator-associated pneumonia.

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Correct Answer is D

Explanation

A. While fluid restriction may be necessary for some clients with heart failure, a general fluid
intake limit of 1,500 mL daily may not be appropriate for all clients. Fluid restriction should be individualized based on the client's clinical status and recommended by the healthcare provider.
B. While a balanced diet, including adequate protein intake, is important for overall health, there is no specific evidence to suggest that a high protein diet is necessary for clients with heart
failure. Dietary recommendations should be individualized based on the client's nutritional needs and medical condition.
C. Range of motion exercises may be beneficial for maintaining joint mobility, but they are not specifically related to managing heart failure symptoms or preventing exacerbations.
D. Weighing every morning is an important self-monitoring strategy for clients with heart failure to assess for fluid retention. Sudden weight gain may indicate fluid accumulation, which can be an early sign of worsening heart failure. Daily weight monitoring allows for early intervention and adjustment of treatment as needed.

A. Gonorrhea. B. Group B Streptococcus. C. Toxoplasmosis. D. Rubella.

Correct Answer is D

Explanation

A. Gonorrhea: While sexually transmitted infections can affect pregnancy, the symptoms described are not consistent with gonorrhea.
B. Group B Streptococcus: Group B Streptococcus is commonly screened for in pregnant individuals but does not typically present with the described symptoms.
C. Toxoplasmosis: Toxoplasmosis can affect pregnancy, but the symptoms described are not specific to toxoplasmosis.
D. Rubella: Rubella infection during pregnancy can lead to congenital rubella syndrome, which can cause birth defects. The symptoms described are consistent with rubella infection.

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Exhibits Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?

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Exhibits

Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?