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Patient Data

Exhibits

What order(s) would the nurse question? (Select all that apply.)

Send blood for a complete blood count, electrolytes

Enalapril 10 mg every morning

C Ibuprofen 400 mg every 4 to 6 hours PRN for temperature greater than 100.5°F (38° C)

Admit to the medical floor

Supplemental oxygen 10 L/min via nasal cannula

Vital signs every 4 hours

Continuous pulse oximetry

Chest x-ray

Answer and Explanation

Correct Answer : C,E,H

A. Send blood for a complete blood count, electrolytes: This is appropriate for assessing the client's overall health status and electrolyte balance, which may be affected by pneumonia and enalapril therapy.

B. Enalapril 10 mg every morning: This is the client's maintenance dose of enalapril for managing hypertension, and it should be continued unless there are specific contraindications or concerns about renal function.

C. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase blood pressure and interfere with the antihypertensive effects of enalapril. Additionally, NSAIDs can potentially worsen renal function, which may already be compromised in a client with pneumonia.
D. Admit to the medical floor: This is appropriate for a client with pneumonia who may require close monitoring and management of respiratory status and other complications.
E. Supplemental oxygen 10 L/min via nasal cannula: High-flow oxygen can decrease respiratory drive and potentially worsen ventilation-perfusion (V/Q) matching, especially in clients with pneumonia.

F. Vital signs every 4 hours: Regular monitoring of vital signs is essential for assessing the client's response to treatment and identifying any signs of deterioration.

G. Continuous pulse oximetry: Continuous pulse oximetry provides real-time monitoring of oxygen saturation and helps assess the effectiveness of oxygen therapy and the client's respiratory status.

H. While a chest x-ray is often indicated for diagnosing pneumonia, ordering it "now" may not be necessary unless the client's condition is unstable or if there are specific concerns regarding the severity of the pneumonia

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Free Nursing Study Resources

Correct Answer is A

Explanation

Hydromorphone is an opioid analgesic that can cause constipation as a side effect by slowing down gastrointestinal motility. Prolonged use of opioids, such as hydromorphone, increases the risk of developing opioid-induced constipation (OIC), which can lead to discomfort, bowel obstruction, and other complications if left untreated.

B. Edema is not typically associated with hydromorphone use, especially when administered for a short duration.

C. Hydromorphone administration is not typically associated with significant alterations in heart rate or rhythm, especially when administered at appropriate doses.

D. hydromorphone administration is not typically associated with alterations in blood glucose levels. Therefore, assessing capillary glucose levels may not be the most relevant assessment in this scenario.

A. Observe pupil response of the right eye. B. Turn, cough, and deep breathe every 2 hours. C. Sleep flat in a supine position. D. Administer a stool softener.

Correct Answer is D

Explanation

D A stool softener can help prevent straining during bowel movements, which could increase intraocular pressure and potentially harm the surgical site. Additionally, the nurse should advise the client to avoid activities that could increase pressure in the eye, such as bending at the waist, lifting heavy objects, or engaging in strenuous activities for a certain period post-surgery.

A Monitoring for changes in pupillary sizes is not specific to this type of surgery.

B Turn, cough, and deep breathe every 2 hours: This instruction is more relevant for clients who have undergone surgery or are at risk of developing respiratory complications, such as pneumonia. It is not specifically related to cataract extraction with a lens implant.

C Clients are usually advised to sleep with the head elevated or to avoid lying on the operative side to minimize the risk of intraocular pressure changes and discomfort.

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Patient Data Exhibits What order(s) would the nurse question? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Correct Answer is A

Explanation

Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant?

Correct Answer is D

Explanation

Patient Data Exhibits What should the nurse do before applying the face mask? Select that apply.

The healthcare provider prescribes bismuth subsalicylate, metronidazole, tetracycline, and pantoprazole for a client with a Helicobacter pylori (H. pylori) infection. Prior to administering the H. pylori treatment regimen, the nurse should review the electronic medical record for which medication?

Patient Data Exhibits What order(s) would the nurse question? (Select all that apply.)

When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

An adult client with multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 mL of DW to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many glt/minute? (Enler numeric value only. If rounding is required, round to the nearest whole number.)

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?

Patient Data

Exhibits

What order(s) would the nurse question? (Select all that apply.)