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

Explanation

A. A nasogastric tube prescribed for low intermittent suction is intended to remove gastric contents and prevent accumulation of air and secretions. If the suction is turned off gastric contents can accumulate, risk of vomiting and aspiration increases, especially in a sedated client with a reduced gag reflex, abdominal distention and discomfort may occur, and postoperative complications can develop quickly. Because aspiration directly threatens airway and breathing, this finding requires immediate intervention.

B. A Hemovac drain must be compressed to maintain negative pressure. If not compressed, drainage may not be effective, but this is not immediately life-threatening compared to airway/aspiration risk
C. An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D. Oxygen up to 4 L/min via nasal cannula typically does not require humidification in most clinical settings. May cause mild dryness but is not an immediate threat to airway or life.

A. Length of time of the exposure to tuberculosis. B. Current diagnosis of hepatitis B. C. History of intravenous drug abuse. D. Conversion of the client's purified protein derivative (PPD) skin test from negative to positive.

Correct Answer is B

Explanation

A. While the length of exposure can be relevant, it is not the most critical factor before starting isoniazid.
B. Isoniazid can cause hepatotoxicity, so a current diagnosis of hepatitis B is crucial to note as it increases the risk of liver damage.
C. A history of intravenous drug abuse is important for overall health assessment but is less critical than current liver disease.
D. Conversion of the PPD test indicates TB exposure, but assessing liver function and potential for hepatotoxicity is more urgent before starting the medication.

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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

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Correct Answer is A

Explanation

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Correct Answer is B

Explanation

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Patient Data Exhibits Which assessment findings indicate that the client has stabilized? Select all that apply.

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.