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 B
Explanation
A. NSAIDs are not associated with the characteristic features of truncal obesity, moon face, and buffalo hump.
B. Corticosteroids can cause truncal obesity, moon face, and buffalo hump as side effects due to their effects on metabolism and fat distribution.
C. Thyroid replacement hormone is used to treat hypothyroidism and does not cause the symptoms described.
D. Insulin is used to manage diabetes and does not typically cause the features seen in Cushing’s syndrome associated with corticosteroid use.
Correct Answer is D
Explanation
A. Urinary output of 50 mL/hour is within normal limits and does not directly impact morning care instructions.
B. An oxygen saturation measurement of 95 to 96% is generally acceptable and does not necessitate specific morning care instructions.
C. A blood pressure of 144/84 mm Hg is elevated but not critical in the context of morning care instructions for the UAP.
D. Orientation to person only indicates a cognitive impairment that could affect the client’s ability to understand or follow instructions, cooperate during care, and ensure safety during activities like bathing or moving. This is the most critical factor to consider when providing instructions to the UAP.
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