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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

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

B. When purulent drainage is observed at a wound site, obtaining a culture of the drainage is essential for identifying the specific microorganisms causing the infection and determining their sensitivity to antibiotics.

A. Serum blood glucose level is not directly relevant to the assessment of purulent drainage at a wound site.

C. An elevated CRP level may indicate the presence of infection but obtaining a CRP level may not be as immediate or specific as obtaining a wound culture.

D. Blood pH level is not directly relevant to the assessment of purulent drainage at a wound site.

A. Encourage deep breathing and coughing exercises. B. Obtain vital signs every 2 hours during hospitalization. C. Provide an eye shield to be worn while sleeping. D. Teach a family member to administer eye drops.

Correct Answer is C

Explanation

C. After eye surgery, especially when there's been trauma like glass removal, it's crucial to protect the eye from further injury, particularly during sleep when movements may be involuntary and less controlled. An eye shield helps prevent inadvertent rubbing or trauma to the eye, promoting healing and reducing the risk of complications.

A. While deep breathing and coughing exercises are important for preventing respiratory complications after surgery, they are not the immediate intervention required following surgical removal of glass from the eye.

B. Monitoring vital signs is essential for assessing the client's overall health status and detecting any signs of complications. However, it is not a priority

D. While administering eye drops may be a part of postoperative care, it's not the immediate intervention required right after the surgical removal of glass from the eye.

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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

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is B

Explanation

A client is recovering from the surgical removal of glass in the right eye. Which intervention should the nurse implement immediately following the procedure?

Correct Answer is C

Explanation

Patient Data Exhibits Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?

The antitubercular drug isoniazid is prescribed for a client with active tuberculosis. To evaluate the effectiveness of this medication, which outcome can the nurse expect this client to exhibit?

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

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

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

Patient Data

Exhibits

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