Exhibits
Based on the current focused assessment, what prescriptions should the practical nurse (PN) ask the health care provider to add? Select all that apply.
Give ibuprofen 400 mg PO every 6 hours PRN for fever
Give 1,000 mL sodium chloride now
Discontinue the peripheral IV
Insert an indwelling urinary catheter
Apply cardiac telemetry monitoring
Collect blood to test electrolyte levels
Prepare to defibrillate the client
Collect blood for a type and screen
Correct Answer : A,E,F
A. Give ibuprofen 400 mg PO every 6 hours PRN for fever
The client has a fever of 101.5° F (38.6° C), so administering ibuprofen to manage the fever is appropriate.
B. Give 1,000 mL sodium chloride now
This prescription is already ordered and being administered, so it does not need to be requested again.
C. Discontinue the peripheral IV
The client needs IV access for fluid administration and potential medications, so discontinuing the peripheral IV is not appropriate.
D. Insert an indwelling urinary catheter
There is no indication of urinary retention or need for precise fluid measurement, making this intervention unnecessary at this time.
E. Apply cardiac telemetry monitoring
Given the client's elevated heart rate and respiratory rate, cardiac telemetry monitoring would help in continuously assessing the client's cardiac status.
F. Collect blood to test electrolyte levels
Due to the client's symptoms and history of decreased fluid intake, electrolyte imbalance is a concern, and testing electrolyte levels is necessary.
G. Prepare to defibrillate the client
There is no indication of a cardiac emergency that would require defibrillation.
H. Collect blood for a type and screen
There is no indication of the need for a blood transfusion, making this intervention unnecessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"C"},"F":{"answers":"A"}}
Explanation
- Leaving an Older Adult in a Public Space
- Abandonment: Leaving the client alone in a public space can be considered abandonment, as it involves a failure to provide necessary care and supervision.
- Untreated Pressure Injuries
- Neglect: Untreated pressure injuries indicate a failure to provide adequate care and preventative measures, which is a form of neglect.
- Oversedation
- Physical Abuse: Administering excessive medication or sedation without proper medical justification can be a form of physical abuse.
- Poor Personal Hygiene
- Neglect: Poor personal hygiene often results from neglect, where the caregiver fails to assist with or encourage personal care practices.
- Depression or Withdrawn Behavior
- Neglect: Depression or withdrawn behavior can result from neglectful conditions, such as a lack of social interaction or emotional support.
- Bruises in Various Stages of Healing
- Physical Abuse: Bruises in various stages of healing are a classic sign of physical abuse, indicating that the client has been subjected to physical harm.
Correct Answer is C
Explanation
A. Placing the client in front of the nurse can be disorienting and unsafe, especially since the client has limited vision with the eye shield. The PN should be in a position to provide guidance and support.
B. Standing in front of the client while leading them could be confusing for the client, as they might not see where they are going. The PN should be positioned where they can offer clear support and direction.
C. Walking on the client’s left side is the best approach as it ensures that the PN is on the side of the unaffected eye. This position allows the PN to guide and support the client while the shielded eye is protected from potential hazards.
D. Supporting the client on the right side could interfere with the eye shield and the healing process. The PN should assist from the left side to avoid disturbing the protected eye and to provide better guidance.
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