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Patient Data.

Exhibits

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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Nosocomial transmission in the medical area. Rationale: Nosocomial transmission refers to infections that are acquired in healthcare settings. While it's essential for healthcare professionals to be aware of this risk, the client's presentation of diarrhea in a hurricane disaster area is more likely due to environmental factors rather than hospital-acquired infection.

Choice B rationale:

Food contamination from floodwaters. Rationale: In the aftermath of a hurricane, floodwaters can carry contaminants and pathogens, leading to food contamination. This is a significant concern, and the nurse should educate the client about the potential risks associated with consuming food exposed to floodwaters. However, the primary source of contamination for diarrhea is typically waterborne pathogens, which is addressed in choice C.

Choice C rationale:

Drinking water contaminated by sewage. Rationale: During natural disasters like hurricanes, sewage systems can become compromised, leading to the contamination of drinking water sources. This contamination poses a significant risk for diarrheal illnesses, as sewage often contains harmful pathogens. Therefore, the nurse should consider this as the most probable source of the client's exposure.

Choice D rationale:

Close living quarters at evacuation centers. Rationale: Close living quarters in evacuation centers can contribute to the spread of infectious diseases, including diarrheal illnesses. However, in this scenario, the client's chief complaint is diarrhea, and the nurse should prioritize investigating potential sources of waterborne contamination, as this aligns more closely with the client's symptoms.

A. Reassure the client that someone will check on him hourly. B. Place fresh water and a glass within reach on the bedside table. C. Ensure that the call bell is easily accessible to the client. D. Offer the client an evening snack before providing oral care.

Correct Answer is C

Explanation

The correct answer is choice C: Ensure that the call bell is easily accessible to the client.

Choice C rationale: Ensuring that the call bell is easily accessible empowers the client to promptly request assistance if needed during the night. This promotes safety and reduces anxiety, as the client can quickly contact the nurse if they experience an urgent need to use the restroom or require any other assistance during the night.

Choice A rationale: Reassuring the client that someone will check on him hourly may provide some comfort, but it does not directly address the client's issue of urinary frequency. Ensuring easy access to the call bell is a more targeted approach to managing the client's needs.

Choice B rationale: Placing fresh water and a glass within reach on the bedside table is a good practice to maintain hydration, but it does not directly address the client's urinary frequency issue.

Choice D rationale: Offering an evening snack and oral care is essential for the client's overall well-being, but it is not directly related to managing the client's urinary frequency at night. The primary focus should be on ensuring that the client can access assistance quickly when needed.

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Patient Data. Exhibits Which order would the nurse question? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

Correct Answer is C

Explanation

When caring for an older male client with urinary frequency, which measure is most important for the nurse to implement to help the client prepare to go to bed for the night?

Correct Answer is C

Explanation

A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (Rank the first action at the top with the remainder in descending order.).

The medication aide at a long-term care facility is sick and requests to go home before all medications are administered. Which action should the practical nurse (PN) in charge take?

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? (Select all that apply.).

The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide. Which information should be included in the discharge instructions?

A nurse is instructing a nursing assistant on how to assist a patient with bathing. The patient has hemiparesis on the left side due to a stroke. Which of the following statements by the nursing assistant demonstrates understanding of the teaching?

The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

A nurse is teaching a group of older adults about the effects of aging on the neurological system. Which of the following statements should the nurse include as correct? (Select all that apply.).

Patient Data.

Exhibits

Which order would the nurse question? Select all that apply.