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
Explanation
A. Folic acid deficiency is the most significant maternal factor associated with the development of spina bifida occulta. Adequate folic acid intake before and during pregnancy is crucial for preventing neural tube defects.
B. Preeclampsia is a serious pregnancy complication but does not have a direct link to spina bifida occulta compared to the impact of folic acid deficiency.
C. A short interval between pregnancies is associated with other risks but is not a known direct cause of spina bifida occulta.
D. Tobacco use has various adverse effects on pregnancy and fetal development but is not as directly linked to the risk of spina bifida occulta as folic acid deficiency.
Correct Answer is C
Explanation
A. Describing the procedure in detail can increase anxiety or focus the client on the pain rather than distracting them from it.
B. Asking the client to describe the pain could heighten their awareness of it, which is counterproductive to the goal of distraction.
C. Encouraging the client to reminisce about a favorite past family event is a distraction technique that shifts the client's focus away from the pain, helping to manage discomfort during the procedure.
D. Explaining alternative pain management strategies is useful but not a distraction technique; it does not provide immediate relief or shift the client's focus during the procedure.
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