Patient Data

Exhibits

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

Answer and Explanation

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.

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

Explanation

In the provided scenario, the two key pieces of subjective data indicating the need for health interventions are the client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise. These details suggest that the client's asthma is not well-controlled, and the ineffectiveness of the rescue medication, especially with an expired inhaler, warrants immediate medical attention.

A. Assess for increasing fluid volume overload. B. Withhold next scheduled dose of treatment. C. Increase neurologic checks to every 2 hours. D. Maintain the prescribed fluid restriction.

Correct Answer is D

Explanation

A. Assessing for increasing fluid volume overload is not indicated with a rising serum sodium level; instead, it suggests correction of hyponatremia, a common complication of SIADH.

B. Withholding the next scheduled dose of treatment is not appropriate based solely on a rise in serum sodium level within the normal range.

C. Increasing neurologic checks may be necessary in severe cases of hyponatremia but is not directly indicated by a rise in serum sodium within the normal range.

D. Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.

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Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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

Explanation

Correct Answer is D

Explanation

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Patient Data

Exhibits

What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.