Exhibits

Which of the following 3 provider prescriptions does the nurse anticipate?

Regular insulin 20 units subcutaneously

Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L

Initiate cardiac monitoring

0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr

Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L

Dextrose 5% in water (DSW) intravenous at 5 ml/kg/hr for 4 hr

Blood glucose checks every 4 hr

Insert indwelling urinary catheter

Answer and Explanation

Correct Answer : B,D,E

. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L

The client's potassium level is slightly elevated at 5.5 mEq/L. Potassium replacement may be necessary if the level drops below 5.0 mEq/L, which is within the anticipated range for the nurse's actions.

D.0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr

This prescription addresses the need for fluid resuscitation to correct dehydration and electrolyte imbalances often seen in DKA. The client's initial blood pressure of 96/65 mm Hg suggests some degree of dehydration, further supporting the use of isotonic saline.

E.Regular insulin continuous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L

This prescription aligns with the client's presentation of severe hyperglycemia (468 mg/dL) and acidosis (pH 7.30), indicating diabetic ketoacidosis (DKA). Insulin infusion is crucial for lowering blood glucose levels and correcting acidosis.

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Free Nursing Study Resources

Correct Answer is C

Explanation

C. Monitoring urine output is crucial in the early postoperative period after a kidney transplant to assess kidney function and ensure adequate perfusion.

A Managing pain is important, but the administration of opioids should be carefully considered due to their potential to mask symptoms and side effects that could be critical in the postoperative period.

B. While electrolyte imbalances are important to monitor, hypokalemia specifically is not typically associated with acute rejection in the early postoperative period.

D. Blood pressure monitoring every 8 hours may not be sufficient in the immediate postoperative period, especially given the potential for fluid shifts and changes in hemodynamic status.

A. "Suction pressure that is too high causes this." B. "Your breathing pattern causes this." C. "This indicates a possible air leak." D. "This means your lung is fully re-expanded."

Correct Answer is B

Explanation

B. Changes in the fluid level of the water-seal chamber correspond to the client's breathing pattern. During inhalation, the negative pressure in the chest cavity may cause the fluid level to rise slightly as air is drawn into the tube, and during exhalation, the fluid level may fall as air exits through the chest tube.

A Fluctuations in the fluid level can occur due to changes in suction pressure settings, but this is more relevant to the suction control chamber rather than the water-seal chamber.

C. If there is continuous bubbling in the water-seal chamber, it indicates an air leak, which disrupts the normal function of the water-seal mechanism.

D. The water-seal chamber's fluctuation does not directly indicate lung re-expansion. Lung re-expansion is assessed through clinical examination, chest X-ray, or other diagnostic tests rather than the water-seal chamber.

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Exhibits Which of the following 3 provider prescriptions does the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?

A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations?

A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy?

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A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take?

Exhibits

Which of the following 3 provider prescriptions does the nurse anticipate?