Patient Data.

Exhibits

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

Click to mark whether the assessment finding represents a therapeutic result of the sodium bicarbonate administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.

Capillary refill 2 seconds

Blood pressure 113/72 mm Hg

Bicarbonate 22 mEq/L (22 mmol/L)

Sodium 152 mEq/L (152 mmol/L)

400 mL urine output

Heart rate 77 beats/minute

Answer and Explanation

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

Choice A: Capillary refill 2 seconds

Reason: Capillary refill time is a quick test to assess peripheral perfusion and hydration status. A normal capillary refill time is less than 2 seconds. Initially, the patient had a capillary refill time of 5 seconds, indicating poor perfusion, likely due to dehydration from vomiting and diarrhea. After the administration of IV fluids and sodium bicarbonate, the capillary refill time improved to 2 seconds, which is within the normal range. This improvement indicates that the treatment was effective in restoring adequate perfusion and hydration, making it a therapeutic result.

Choice B: Blood pressure 113/72 mm Hg

Reason: Normal blood pressure for adults is typically around 120/80 mm Hg. The patient’s initial blood pressure was 100/77 mm Hg, which is on the lower side, likely due to dehydration. After receiving IV fluids and sodium bicarbonate, the blood pressure improved to 113/72 mm Hg, which is closer to the normal range. This indicates that the treatment helped to stabilize the patient’s blood pressure, making it a therapeutic result.

Choice C: Bicarbonate 22 mEq/L (22 mmol/L)

Reason: The normal range for bicarbonate (HCO3) is 21 to 28 mEq/L. The patient’s initial bicarbonate level was 15 mEq/L, indicating metabolic acidosis, likely due to severe vomiting and diarrhea. After the administration of sodium bicarbonate, the bicarbonate level increased to 22 mEq/L, which is within the normal range. This indicates that the sodium bicarbonate effectively corrected the metabolic acidosis, making it a therapeutic result.

Choice D: Sodium 152 mEq/L (152 mmol/L)

Reason: The normal range for sodium is 135 to 145 mEq/L. The patient’s sodium level of 152 mEq/L is above the normal range, indicating hypernatremia. This could be a non-therapeutic side effect of the sodium bicarbonate administration, as sodium bicarbonate can increase sodium levels in the blood. Hypernatremia can lead to symptoms such as confusion, muscle twitching, and seizures, and requires careful monitoring and management.

Choice E: 400 mL urine output

Reason: The patient’s urine output of 400 mL is not directly related to the administration of sodium bicarbonate. Urine output is influenced by various factors, including fluid intake, kidney function, and overall hydration status. In this case, the urine output is more likely related to the patient’s overall fluid balance and hydration status rather than a direct effect of the sodium bicarbonate. Therefore, it is considered an unrelated finding.

Choice F: Heart rate 77 beats/minute

Reason: A normal resting heart rate for adults ranges from 60 to 100 beats per minute. The patient’s initial heart rate was 102 beats per minute, which is elevated, likely due to dehydration and metabolic acidosis. After receiving IV fluids and sodium bicarbonate, the heart rate decreased to 77 beats per minute, which is within the normal range. This indicates that the treatment helped to stabilize the patient’s heart rate, making it a therapeutic result.

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Correct Answer is C

Explanation

Choice A Reason:

Depression screening is important for overall health and well-being, especially in weight management programs where mental health can significantly impact outcomes. However, it is not the primary measure for determining the effectiveness of orlistat. Orlistat works by inhibiting the absorption of fats from the diet, leading to weight loss. Therefore, while mental health monitoring is crucial, it does not directly measure the medication’s effectiveness.

Choice B Reason:

Daily calorie count is a useful tool in weight management programs to ensure that clients are adhering to a calorie-restricted diet. However, it is not a direct measure of the effectiveness of orlistat. While calorie counting can help manage weight, the primary goal of orlistat is to reduce fat absorption, which is better reflected in changes in body weight and BMI.

Choice C Reason:

Body mass index (BMI) is a key indicator of weight management and is directly related to the effectiveness of orlistat. BMI is calculated based on height and weight, providing a clear measure of changes in body weight over time. Monitoring BMI helps determine if the client is losing weight as expected, making it the most appropriate assessment for evaluating the effectiveness of orlistat.

Choice D Reason:

Serum protein levels are important for assessing nutritional status and overall health. However, they do not directly measure the effectiveness of orlistat in a weight management program. Orlistat’s primary function is to reduce fat absorption, and its effectiveness is better assessed through changes in body weight and BMI rather than serum protein levels.

A. Provide a PRN NSAID for gum discomfort. B. Obtain a soft bristle toothbrush for the client. C. Review most recent coagulation lab values. D. Complete a medication variance report. E. Report findings to the healthcare provider.

Correct Answer is ["B"]

Explanation

Choice A Reason:

Providing a PRN NSAID for gum discomfort is not advisable in this situation. NSAIDs can increase the risk of bleeding, which is already a concern for a client on anticoagulants. Therefore, this action could exacerbate the client’s condition and should be avoided.

Choice B Reason:

Obtaining a soft bristle toothbrush for the client is a good practice to help minimize gum irritation and bleeding. Soft bristle toothbrushes are gentler on the gums and can help prevent further bleeding and discomfort, making this a suitable action for the nurse to implement.

Choice C Reason:

Reviewing the most recent coagulation lab values is crucial in this scenario. Coagulation tests, such as INR (International Normalized Ratio) or aPTT (activated partial thromboplastin time), can help determine if the anticoagulant dosage is appropriate or if adjustments are needed. This step is essential to ensure the client’s safety and effective management of their anticoagulation therapy.

Choice D Reason:

Completing a medication variance report is not immediately necessary unless there is evidence of a medication error. The priority should be to address the client’s symptoms and ensure their safety. While documentation is important, it should not take precedence over direct patient care in this situation.

Choice E Reason:

Reporting findings to the healthcare provider is essential. The development of bleeding and new bruises indicates a potential adverse reaction to the anticoagulant. The healthcare provider needs to be informed to assess the situation, possibly adjust the medication, and provide further instructions for managing the client’s condition.

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Naxlex Comprehensive Predictor Exams

A client is receiving orlistat as part of a weight management program. Which ongoing assessment should be included in the plan of care to determine the effectiveness of the medication?

Correct Answer is C

Explanation

After receiving the third dose of a new oral anticoagulant prescription, an older adult client develops bleeding and tender gums and has many new bruises. Which actions should the nurse implement? Select all that apply.

Correct Answer is ["B"]

Explanation

A client with chemotherapy-induced nausea receives a prescription for metoclopramide. Which adverse effect is most important for the nurse to report?

A client who is newly diagnosed with diabetes insipidus (DI) is receiving synthetic vasopressin intravenously. Which side effect of vasopressin reported by the client should the nurse report to the healthcare provider?

A female client starts a new prescription, oxybutynin, for symptoms of an overactive bladder. The client tells the nurse that she is training to run in a half-marathon. Which instruction should the nurse emphasize?

Patient Data The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence. Sentence: The client is at immediate risk for developing: dropdown , dropdown and dropdown.

A client has a prescription for heparin 5000 units IV STAT. Several pre-filled syringes of low molecular weight heparin are available in the client’s medication drawer. Which action should the nurse implement?

The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?

Edited TextA client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?