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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
The prescription requires a 10 mg dose of loratadine.
The bottle indicates the concentration is 5 mg per 5 mL.
One teaspoon is equivalent to approximately 5 mL.
Therefore, to achieve a 10 mg dose, the client would need 10 mg / 5 mg per teaspoon = 2 teaspoons.
The nurse should instruct the client to take 2 teaspoons of the loratadine suspension daily.
Correct Answer is D
Explanation
A. Administering aspirin may be appropriate for suspected ischemic stroke; however, it should not be done without confirmation of diagnosis and evaluation by the stroke team.
B. Initiating pneumatic compression devices is not the priority in this situation. Acute assessment and management of the suspected stroke take precedence.
C. Placing an indwelling urinary catheter and measuring strict intake and output may be necessary for ongoing care but is not the priority when the client is presenting with symptoms suggestive of a stroke.
D. Notifying the stroke team to assist with acute assessment and management is the priority intervention. Time is crucial in the management of stroke, and early intervention can help minimize neurological damage and improve outcomes.
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