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Patient Data

Exhibits

The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Administering antipyretic medication as needed

Educating client and family on the importance of fluid restrictions

Collaborating with dietician to prepare low protein diet

Monitoring fluid status

Investigating acid/base complication

Assessing for worsening respiratory status

Performing diagnostic testing to determine cause of fever

Reassessing vital signs

Identifying cardiac arrhythmias

Answer and Explanation

Correct Answer : D,F,I

A.   Administering antipyretic medication as needed is important for managing the client's fever and improving comfort, but not as urgent as monitoring fluid, respiratory status, and cardiac function.
B.   Client and family education on fluid management is important but can be addressed after assessing hydration status.
C.   Protein restriction might be necessary for CKD management in the long term, but not the most pressing need right now.
D.   Given the client's history of chronic kidney disease, monitoring fluid status is crucial to prevent fluid overload and ensure adequate kidney function. Accurate intake and output measurements, along with daily weights, are essential.
E.   The bicarbonate level (18 mEq/L) is slightly low, but further investigation can come after addressing the infection.
F.   The chest X-ray shows bibasilar infiltrates, and the client has a high respiratory rate.

Continuous assessment of respiratory status is important to detect any signs of respiratory distress or infection, which may require immediate intervention.
G.   Performing diagnostic testing to determine cause of fever is necessary for identifying the underlying infection, but secondary to immediate stabilization efforts.
H.   Reassessing vital signs is vital for ongoing assessment, but integrated into the monitoring of fluid status, respiratory status, and cardiac function.

I.   The client has an elevated potassium level and an irregular heart rate, putting him at risk for cardiac arrhythmias. Continuous ECG monitoring and immediate identification of any arrhythmias are critical to prevent cardiac complications.

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

Explanation

Side positioning can help with pain relief and prevent hypotension, which is beneficial for both maternal and fetal well-being. Urinary drainage (B) is typically a maternal intervention to manage the effects of epidural anesthesia on bladder function. Assisting with pushing efforts is a maternal intervention that supports the mother during the second stage of labor. Administering IV fluids is an intervention for the mother to maintain hydration and blood pressure, which indirectly benefits the fetus. Monitoring blood pressure is essential for both maternal and fetal health, as stable maternal blood pressure is critical for adequate fetal perfusion.

A. Serum potassium of 4.2 mEq/L. (4.2 mmol/L) B. Hemoglobin A1C 7%. C. Total cholesterol 180 mg/dL (4.7 mmol/L). D. Hematocrit 45% (0.45 volume fraction). E. Random plasma glucose level 200 mg/dl (11.1 mmol/L).

Correct Answer is ["B","E"]

Explanation

A. Serum potassium within the reference range is not typically a cause for concern in this scenario.
B. A hemoglobin A1C level of 7% indicates poor glycemic control and may suggest the need for adjustment in diabetes management, as it exceeds the recommended target range.
C. Total cholesterol within the reference range is not the most significant finding to report in this scenario.
D. Hematocrit within the reference range is not the most significant finding to report in this scenario.
E. A random plasma glucose level of 200 mg/dl (11.1 mmol/L) is indicative of hyperglycemia and requires attention as it suggests poor glycemic control, potentially related to diabetes.

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Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have a least one but may have more than response option selected

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

Explanation

Correct Answer is ["B","E"]

Explanation

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Patient Data

Exhibits

The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?