Patient Data
What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.
Increase IV fluids to 150 mL/hr
Monitor for adverse reaction to antibiotics
Repeat CD4+ T-cell count STAT
Initiate airborne isolation
Administer antiemetic
Correct Answer : A,B,E
A. This intervention is likely to be ordered due to the patient's fever and elevated heart rate, which may suggest dehydration or the need for increased fluid intake to support hemodynamic stability and mitigate the effects of fever and potential dehydration from fever and nausea.
B. Given the diagnosis of Pneumocystis pneumonia, the patient will likely be on or start antibiotics specific to this infection, such as trimethoprim-sulfamethoxazole. Monitoring for adverse reactions is crucial, especially in a newly diagnosed HIV- positive patient who might be starting multiple new medications.
C. While it is important to monitor CD4 counts in HIV-positive patients to guide treatment decisions, repeating the CD4 count immediately might not be prioritized unless there are specific clinical changes that suggest a rapid decline in immune function. Given the recent test results showing a CD4 count of 443 cells/mm^3, immediate retesting might not be clinically justified unless guided by other symptoms or considerations not detailed here.
D. Pneumocystis pneumonia does not require airborne isolation as it is not typically contagious between people under normal circumstances. Instead, it arises as an opportunistic infection in individuals with weakened immune systems. Hence, this order would not be appropriate unless there were other infections suspected that require such precautions.
E. The patient reports severe nausea, which not only is distressing but can also prevent the patient from taking oral medications and maintain necessary nutrition. Administering an antiemetic can help manage this symptom effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Palpating the right flank for tenderness is essential to assess for possible renal involvement, such as a kidney infection or kidney stone, which could be causing the urinary symptoms and right lower back pain. However, it is not the initial step.
B. Testing the urine for the presence of hematuria is important in assessing for potential urinary tract infection or other renal pathology but does not directly address the cause of the right lower back pain.
C. Evaluating the urine for a strong odor may provide information about a possible urinary tract infection, but it is not the most immediate intervention for addressing the client's symptoms, compared to measuring the vital signs.
D. Measuring the temperature and pulse rate is important for identifying any signs of systemic infection or inflammation that could be contributing to the patient's symptoms.
Correct Answer is A
Explanation
A. Restricting protein intake is often recommended for clients with glomerulonephritis to reduce the workload on the kidneys and decrease proteinuria. This can help slow the progression of kidney damage.
B. Increasing intake of high-fiber foods may be beneficial for overall health but is not specifically indicated for glomerulonephritis management.
C. Limiting oral fluid intake to 500 mL/day is not appropriate for most clients and may lead to dehydration, which can exacerbate kidney dysfunction.
D. Increasing intake of potassium-rich foods may be contraindicated in some cases of glomerulonephritis, especially if the client has hyperkalemia. Dietary potassium restriction may be necessary depending on the client's lab values and kidney function.
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