Patient Data
Place client on oxygen 2 10 4 liters and maintain oxygen saturation at or above, 959%.
Start the client on antibiotic therapy
STAT complete blood count (CBC), basic metabolic panel (BMP), and blood cultures
Stat ventilation/perfusion (V/Q) of chest
Send sputumn for culture & sensitivity
STAT 2 views chest x-ray
Correct Answer : B,C,E
B. Start the client on antibiotic therapy - Antibiotics are typically prescribed to treat bacterial pneumonia, which is a common cause of pneumonia.
C. STAT complete blood count (CBC), basic metabolic panel (BMP), and blood cultures - These tests help in assessing the severity of the infection, evaluating electrolyte balance, and identifying the causative organism respectively.
E. Send sputum for culture & sensitivity - This helps in identifying the specific organism causing the pneumonia and determining the most effective antibiotic for treatment.
A. At an oxygen saturation above 90%, the client does not necessarily require oxygen supplementation
D. A ventilation/ perfusion scan is needed in cases of suspected pulmonary embolism which is unlikely in this case.
F. Another chest X ray is not important as a recent one is present. No much changes is expected in the period of the few hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Consuming dairy products, especially those rich in milk and cream, can stimulate gastric acid secretion and exacerbate symptoms of a duodenal ulcer. Therefore, it is essential for the nurse to review with the client the importance of avoiding foods that can aggravate the ulcer and worsen symptoms.
B. While reinforcing teaching about dietary modifications is important, encouraging the client to make a list of snack foods high in dairy content would not address the issue of avoiding dairy products to protect the duodenal ulcer.
C. While switching to decaffeinated coffee and tea can be beneficial for individuals with duodenal ulcers, it does not directly address the client's misconception about using dairy products to coat and protect the ulcer.
D. Eating frequent small meals can help reduce discomfort associated with duodenal ulcers by minimizing gastric acid secretion and preventing large fluctuations in stomach volume.
However, this option does not address the client's misconception.
Correct Answer is A
Explanation
A Hematemesis refers to vomiting blood, which can occur when esophageal varices rupture and bleed into the gastrointestinal tract. It is a hallmark sign of upper gastrointestinal bleeding and requires immediate medical attention. Monitoring for hematemesis allows for early detection of variceal bleeding and prompt intervention to prevent further complications.
B Brown, foamy urine may indicate the presence of blood or protein in the urine, which can occur in various kidney and urinary tract disorders.
C Clay-colored stool may indicate a lack of bile in the stool, which can occur in conditions affecting the liver or bile ducts, such as obstructive jaundice.
D Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, including cirrhosis. However, while anorexia may impact nutritional status and overall health, it is not directly related to the complications of esophageal varices.
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