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 B
Explanation
Choice A rationale:
Asking questions in a vague, non-specific format is not the best approach for addressing intimate partner violence. This approach may confuse the client or make them feel uncomfortable, as they may not know what specific information the nurse is seeking. It is essential to use clear and direct communication when addressing sensitive issues like intimate partner violence.
Choice B rationale:
Beginning with questions that are less sensitive in nature is the preferred approach when interviewing a client about intimate partner violence. This allows the nurse to establish rapport and build trust with the client before delving into more sensitive topics. Starting with less sensitive questions can help the client feel more comfortable and willing to share information about their situation.
Choice C rationale:
Getting the most difficult questions over with first is not the best approach when addressing intimate partner violence. Starting with the most challenging questions may cause the client to become defensive or unwilling to cooperate. It is essential to build a therapeutic relationship before discussing sensitive topics to ensure the client's emotional safety and willingness to disclose information.
Choice D rationale:
Sharing personal values to put the client at ease is not an appropriate approach when addressing intimate partner violence. It can be perceived as unprofessional and may compromise the objectivity and neutrality of the nurse in providing care. The focus should be on the client's needs and concerns, not the nurse's personal beliefs.
Correct Answer is B
Explanation
Choice A rationale:
Substituting natural fruit juices for carbonated drinks may be a beneficial dietary change, but it does not address the client's immediate issue of severe pain and inability to bear weight on the right ankle. This choice does not directly address the client's current problem and should not be the priority instruction in discharge teaching.
Choice B rationale:
Encouraging active range of motion to limit stiffness is the most appropriate instruction in this situation. The client's inability to bear weight on the right ankle after making dietary changes may be related to musculoskeletal issues or gouty arthritis. Active range of motion exercises can help prevent stiffness and improve joint function.
Choice C rationale:
Using an electric heating pad when pain is at its worst may provide some comfort, but it does not address the underlying cause of the severe pain in the right ankle. It is important to address the cause of the pain rather than relying solely on symptom management.
Choice D rationale:
Avoiding the consumption of wine, beer, and coffee may be relevant for some medical conditions, but it does not directly address the client's current problem of severe ankle pain and inability to bear weight. It is not the most immediate concern.
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