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Exhibits

Review H and P, laboratory results, flow sheet, and orders.

The nurse notifies the health care provider of the lab values, blood pressure and pulse, and current intake and output.

Which prescriptions does the nurse expect the healthcare provider to write based on the information? Select all that apply.

Turn off the suction on the nasogastric tube

Bolus calcium

Increase the intravenous fluid rate

Add potassium to the intravenous fluids

Administer a diuretic

Flush the central line with 3% sodium chloride

Decrease the percentage of sodium in the intravenous fluids

Answer and Explanation

Correct Answer : A,C,D

A.   Turn off the suction on the nasogastric tube. The client has been experiencing continuous nasogastric (NG) suction, which can lead to fluid and electrolyte imbalances. The client's low blood pressure (86/64 mm Hg), leg cramping, and fatigue suggest volume depletion and possible electrolyte loss. Discontinuing NG suction will help prevent further fluid loss and electrolyte depletion.
B.   Bolus calcium. The client’s calcium levels (9.2 mg/dL and 9.1 mg/dL) are within normal range (8.5–10.2 mg/dL). Since there is no indication of hypocalcemia, a calcium bolus is not necessary.
C.   Increase the intravenous fluid rate. The client’s low blood pressure, tachycardia (96 bpm), and signs of fatigue suggest hypovolemia, likely due to fluid losses from NG suction and inadequate IV fluid replacement. Increasing IV fluid rate can help restore circulatory volume and improve perfusion.
D.   Add potassium to the intravenous fluids. The client’s potassium level has dropped from 3.8 mEq/L to 3.5 mEq/L, which is at the lower limit of normal (3.5–5.0 mEq/L). Prolonged NG suctioning can cause hypokalemia, leading to muscle cramps, weakness, and fatigue. Adding potassium to IV fluids can prevent further decline and correct the deficiency.
E.   Administer a diuretic. The client is already hypovolemic due to NG losses, as evidenced by low blood pressure and tachycardia. A diuretic would further exacerbate volume depletion, making it an inappropriate intervention.
F.   Flush the central line with 3% sodium chloride. The client's sodium levels are normal (139–142 mEq/L), so a hypertonic saline flush (3% NaCl) is not needed. This type of fluid is typically used for severe hyponatremia, which is not present in this case.
G.   Decrease the percentage of sodium in the intravenous fluids. The client is receiving Dextrose 5% in 0.9% sodium chloride, which provides isotonic hydration. Since the sodium level is within normal limits and the client is hypovolemic, reducing sodium concentration in IV fluids is not necessary.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}

Explanation

Pulse of 105 beats/minute – Both mastitis and endometritis
Tachycardia (heart rate >100 bpm) is a systemic response to infection and inflammation, which can occur in both mastitis and endometritis. In mastitis, infection in the breast tissue triggers a systemic inflammatory response, while in endometritis, uterine infection can cause sepsis-related tachycardia.
Feeling chilled, achy, and fatigued – Both mastitis and endometritis
Both conditions can cause systemic flu-like symptoms, including chills, body aches, and fatigue, as the body mounts an immune response. Mastitis leads to generalized malaise due to localized infection and inflammation in the breast, while endometritis causes uterine infection, which can spread if untreated.
Baby fed pumped breast milk – Mastitis
Mastitis often develops due to milk stasis when the breasts are not fully emptied. The client was away from the baby for several hours while feeding pumped milk, which may have led to incomplete drainage of the breast, increasing the risk of bacterial overgrowth and mastitis.
Pain rating of 4 on a 0 to 10 scale – Mastitis
Pain in mastitis is usually localized to the affected breast, presenting as a red, firm, warm area. The uterine pain in endometritis is generally more cramp-like and associated with uterine tenderness, rather than a focal area of pain like in mastitis.
Foul-smelling lochia rubra at 2 weeks postpartum – Endometritis
Lochia should transition from rubra (red) to serosa (pink-brown) to alba (white/yellow) within 2 weeks postpartum. Foul-smelling, persistent lochia rubra is a hallmark sign of endometritis, indicating bacterial overgrowth in the uterus.
Temperature of 101.2° F (38.4°C) – Both mastitis and endometritis
Fever is a key symptom of both mastitis and endometritis as the body responds to infection. Mastitis causes localized breast infection with systemic symptoms, while endometritis results in uterine infection and systemic inflammatory response.

A. Begin prescribed intravenous antibiotic administration. B. Schedule the child for a STAT magnetic resonance imaging (MRI) of the neck. C. Obtain bedside trays for intubation or tracheotomy by the healthcare provider. D. Provide a nebulizer treatment with bronchodilators.

Correct Answer is C

Explanation

A. Begin prescribed intravenous antibiotic administration. While IV antibiotics are essential for treating bacterial infections such as epiglottitis, securing the airway is the priority in this child with severe respiratory distress. Antibiotic therapy should be initiated after airway stabilization to prevent further deterioration.
B. Schedule the child for a STAT magnetic resonance imaging (MRI) of the neck. An MRI is not appropriate in an emergency airway situation, as it requires the child to remain still and may delay critical interventions. A clinical diagnosis of epiglottitis is based on symptoms, and confirmation is typically done with lateral neck X-rays only if the airway is stable.
C. Obtain bedside trays for intubation or tracheotomy by the healthcare provider. The child’s symptoms—high fever, drooling, anxiety, and a tripod sitting position—are classic signs of epiglottitis, a life-threatening condition caused by Haemophilus influenzae type B (Hib). Immediate airway management is critical, as swelling of the epiglottis can rapidly lead to complete airway obstruction. Equipment for emergency intubation or tracheotomy must be readily available.
D. Provide a nebulizer treatment with bronchodilators. Nebulized bronchodilators are used for conditions like asthma or croup but are ineffective in epiglottitis, which is caused by inflammation and swelling of the supraglottic structures. Administering nebulized treatments may further distress the child and increase the risk of airway obstruction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits For each assessment finding, click to indicate whether findings from this client's assessment are generally associated with mastitis, endometritis, or could be a sign of both conditions. Each row must have only one response option selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"C"}}

Explanation

A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse implement next?

Correct Answer is C

Explanation

The mother of a 4-month-old baby girl asks the nurse when should she introduce solid foods to her infant. The mother states, "My mother says I should put rice cereal in the baby's bottle now. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?

A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled "Isoniazid Oral Solution, USP 50 mg per 5 mL." How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what is the purpose of the ointment. Which response by the nurse will best explain the purpose for administering the ointment?

A newborn is delivered by cesarean section to a mother who is HIV-positive. The mother received antiretroviral therapy during pregnancy. Which intervention should the nurse implement?

A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?

Exhibits Which description(s) by the client should help confirm that the mastitis has been resolved and breastfeeding/breast health is well maintained? Select all that apply.