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. Infection: While infection can cause localized redness and swelling, deep vein thrombosis (DVT) is a more likely cause given the client's immobility and other risk factors.
B. Fat emboli: Fat emboli typically occur after trauma or orthopedic procedures, and their presentation is less likely in this scenario.
C. Pulmonary embolism: While a pulmonary embolism is a potential complication of DVT, it presents with symptoms such as dyspnea, chest pain, and tachypnea, rather than localized redness and swelling in the calf.
D. Deep vein thrombosis: This condition, characterized by redness and swelling in the affected limb, is common in immobile patients and those with dehydration, making it the most likely cause of the client's symptoms.

A. The client's daily blood pressure will be less than 140/80 mm Hg this month. B. The nurse will encourage the client to walk thirty minutes every day. C. The client will monitor blood glucose and blood pressure after each meal. D. The client's blood pressure readings will be less than 160/90 mm Hg.

Correct Answer is A

Explanation

A. A goal of maintaining a blood pressure less than 140/80 mm Hg aligns with recommended targets for clients with cardiovascular disease to reduce the risk of complications.
B. While physical activity is beneficial, stating that the nurse will encourage the client to walk is not a measurable client-centered outcome. A better outcome would focus on the client’s actions.
C. Monitoring blood glucose is more relevant for diabetes management rather than a primary outcome for cardiovascular disease.
D. A target of less than 160/90 mm Hg is too high and does not align with standard guidelines for blood pressure control in cardiovascular disease.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

Correct Answer is D

Explanation

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is A

Explanation

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

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Exhibits

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