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 C
Explanation
A. Providing lab results to the parent without the client's consent violates the client’s right to privacy under HIPAA (Health Insurance Portability and Accountability Act).
B. While the healthcare provider may discuss results, the nurse must first ensure the client has given consent for the parent to receive medical information.
C. Since the client is an adult (22 years old), their medical information is confidential. The nurse can only share information with the parent if the client provides explicit consent.
D. This response is inappropriate and dismissive, potentially damaging the nurse-client relationship. A professional and respectful explanation should be given.
Correct Answer is A
Explanation
A. Redness and swelling of the calf are classic signs of deep vein thrombosis (DVT), especially in an older adult who is immobile. DVT is a common complication in hospitalized patients, particularly those who are immobile or have other risk factors such as dehydration.
B. Fat emboli typically present with symptoms such as dyspnea, tachypnea, and petechial rash, rather than localized redness and swelling of the calf.
C. Pulmonary embolism typically presents with symptoms such as chest pain, dyspnea, tachypnea, and hemoptysis, rather than localized redness and swelling of the calf.
D. While infection can cause localized redness and swelling, the presence of dehydration and immobility increases the likelihood of a thrombotic event such as deep vein thrombosis. It is important to consider DVT as a potential cause of these findings and initiate appropriate diagnostic and preventive measures.
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