Patient Data.
Which order would the nurse question? Select all that apply.
Ibuprofen 400 mg every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C).
Enalapril 10 mg every morning.
Supplemental oxygen 10 L/min via nasal cannula.
Continuous pulse oximetry.
Send blood for a complete blood count, electrolytes, blood cultures, and procalcitonin.
Admit to the medical floor.
Vital signs every 4 hours.
Correct Answer : A,B,C
Choice A rationale:
Ibuprofen 400 mg every 4 to 6 hours as needed for temperature greater than 100.5 °F (38 °C). This order is questionable because ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can potentially increase blood pressure, which could be harmful to a patient with hypertension. Furthermore, NSAIDs can mask the symptoms of infection, which could delay the diagnosis and treatment of serious infections.
Choice B rationale:
Enalapril 10 mg every morning. This order is questionable because enalapril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. However, ACE inhibitors can cause a dry cough, which could exacerbate the patient’s existing cough due to pneumonia. Additionally, ACE inhibitors can potentially cause hyperkalemia (high potassium levels), so it’s important to monitor the patient’s electrolyte levels.
Choice C rationale:
Supplemental oxygen 10 L/min via nasal cannula. This order is questionable because a high flow rate of oxygen can potentially cause oxygen toxicity or hyperoxia, which can lead to cellular damage. The typical flow rate for a nasal cannula is between 1-6 L/min. A flow rate of 10 L/min may be too high for this patient, especially without a specified target SpO2 range.
Choice D rationale:
Continuous pulse oximetry. This order is appropriate because it allows for continuous monitoring of the patient’s oxygen saturation levels, which is crucial in a patient with pneumonia and shortness of breath.
Choice E rationale:
Send blood for a complete blood count, electrolytes, blood cultures, and procalcitonin. This order is appropriate because these tests can help monitor the patient’s overall health status and response to treatment.
Choice F rationale:
Admit to the medical floor. This order is appropriate because the patient requires hospitalization for treatment and monitoring due to his pneumonia.
Choice G rationale:
Vital signs every 4 hours. This order is appropriate because it allows for regular monitoring of the patient’s vital signs, which can help detect any changes in his condition.
Choice H rationale:
Chest x-ray now. This order is appropriate because a chest x-ray can help confirm the diagnosis of pneumonia and assess its severity.
Choice I rationale:
Sputum culture and sensitivity. This order is appropriate because it can help identify the specific organism causing the pneumonia and determine its antibiotic sensitivity, which can guide antibiotic therapy.
Choice J rationale:
Levofloxacin 500 mg intravenously every 24 hours. This order is appropriate because levofloxacin is a broad-spectrum antibiotic commonly used to treat pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","H"]
Explanation
Choice A rationale:
A Speech Therapist is crucial in this case. The patient presented with garbled speech, which indicates a possible speech impairment. A speech therapist can evaluate the patient’s speech and language skills and provide therapy to improve any deficits, which can significantly enhance the patient’s quality of life.
Choice B rationale:
A Case Manager is essential in coordinating the patient’s care. They ensure that the patient’s healthcare needs are met and that the patient is receiving appropriate treatments. They also coordinate with various healthcare professionals and may assist with insurance issues or discharge planning.
Choice C rationale:
A Physical Therapist can help the patient regain physical strength and mobility that might have been affected by the stroke. They can provide exercises and treatments to improve balance, coordination, and muscle strength, which can help the patient regain independence in their daily activities.
Choice D rationale:
A Pharmacy Technician is not typically involved in direct patient care or recovery. Their role is more focused on assisting pharmacists with dispensing medication and other administrative tasks in a pharmacy setting.
Choice E rationale:
The Chief Nursing Officer (CNO) is a high-level executive role that oversees nursing staff across an entire healthcare organization. While they play a crucial role in ensuring quality nursing care, they would not be directly involved in individual patient recovery.
Choice F rationale:
A Respiratory Therapist could be helpful if the patient had respiratory issues or complications related to the stroke, but given the information provided, it does not appear that respiratory therapy is needed in this case.
Choice G rationale:
A Medical Assistant typically performs administrative and clinical tasks in healthcare settings but does not specialize in rehabilitation or recovery care for stroke patients.
Choice H rationale:
An Occupational Therapist is vital for stroke recovery. They can help the patient regain skills needed for daily living activities that might have been affected by the stroke, such as eating, dressing, and bathing. They can also provide strategies to compensate for any lasting deficits from the stroke. In summary, for a comprehensive recovery plan for this patient who has had a stroke, an interdisciplinary team involving a Speech Therapist (A), Case Manager (B), Physical Therapist ©, and Occupational Therapist (H) would be most beneficial.
Correct Answer is A
Explanation
Choice A rationale:
Instructing the UAP to apply a warm blanket and massage the client's back is the appropriate intervention in response to the client's complaints of feeling dizzy and cold during a fecal impaction removal procedure. These symptoms suggest a vasovagal response, which can be managed by keeping the client warm and providing comfort. This intervention helps increase blood flow and alleviate symptoms.
Choice B rationale:
Inserting a gloved finger into the rectum and massaging the rectal sphincter is not the first-line intervention when a client complains of feeling dizzy and cold during a fecal impaction removal. This invasive procedure should be reserved for cases where other interventions have failed, and it is necessary to complete the impaction removal.
Choice C rationale:
Stopping the procedure and observing for a reduction in symptoms before continuing is a reasonable approach, but it does not address the immediate discomfort and distress the client is experiencing. Providing comfort measures, such as applying a warm blanket and massaging the client's back, should be the initial response.
Choice D rationale:
Encouraging the client to take slow, deep breaths while continuing the procedure may not be effective in addressing the client's symptoms of dizziness and coldness. The client may require immediate comfort measures to stabilize their condition.
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