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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.

Chest x-ray now.

Sputum culture and sensitivity.

Levofloxacin 500 mg intravenously every 24 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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale:

Provide a safe and calm environment for the client during a panic attack. Creating a safe and calm environment is crucial during a panic attack. It can help the client feel more secure and reduce the intensity and duration of the panic attack.

Choice B rationale:

Use therapeutic communication skills to establish rapport and trust with the client. Therapeutic communication is essential for clients with panic disorder. It helps establish a trusting relationship between the nurse and the client, which is crucial for effective treatment and support.

Choice C rationale:

Educate the client about panic disorder and its treatment options. Educating the client about their condition and available treatment options empowers them to make informed decisions about their care. It also reduces anxiety and fear associated with the disorder.

Choice D rationale:

Encourage the client to participate in cognitive-behavioral therapy (CBT). Cognitive-behavioral therapy is a well-established and effective treatment for panic disorder. Encouraging the client to participate in CBT can help them develop coping strategies and manage their symptoms.

Choice E rationale:

Refer the client to self-help groups for peer support and education. Self-help groups can provide valuable peer support and education to individuals with panic disorder. Being part of such a group can reduce feelings of isolation and provide practical advice for managing the condition.

A. A bedside commode is positioned near the bed. B. A full pitcher of water is on the bedside table. C. The client is lying in a supine position in bed. D. A saline lock is present in the right forearm. E. A low sodium diet tray was brought to the room.

Correct Answer is ["C","E"]

Explanation

Choice A rationale:

A bedside commode is positioned near the bed. Positioning a bedside commode near the bed is appropriate for a client with heart failure and COPD who may have mobility issues or difficulty walking to the bathroom. It promotes safety and convenience for the client.

Choice B rationale:

A full pitcher of water is on the bedside table. While it's essential to keep clients with heart failure adequately hydrated, having a full pitcher of water within easy reach might encourage excessive fluid intake, which can exacerbate heart failure symptoms. However, this choice is not an immediate risk requiring intervention.

Choice C rationale:

The client is lying in a supine position in bed. A client with heart failure and COPD should not be lying in a supine position because it can exacerbate respiratory distress and increase the workload of the heart. This is an observation that requires immediate intervention, such as repositioning the client to an upright or semi-fowler's position.

Choice D rationale:

A saline lock is present in the right forearm. The presence of a saline lock is a standard precaution in a hospitalized client and does not require immediate intervention unless there are specific issues with it, such as signs of infection or dislodgement. It does not pose an immediate harm to the client.

Choice E rationale:

A low sodium diet tray was brought to the room. A low sodium diet is crucial for managing heart failure because excessive sodium intake can lead to fluid retention and exacerbate symptoms. Ensuring that the client follows the prescribed diet is essential for their well-being, and any deviations may require immediate intervention.

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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 nurse is providing interventions for a client with panic disorder.Which interventions should the nurse include in the plan of care? (Select all that apply).

Correct Answer is ["A","B","C","D","E"]

Explanation

A client is admitted with an exacerbation of heart failure secondary to chronic obstructive pulmonary disease (COPD). Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.).

Correct Answer is ["C","E"]

Explanation

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. Which action should the nurse take first?

After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields. Which action should the nurse take next based on the assessment?

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

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

Patient Data. What is the rationale for the order of supplemental oxygen 10 L/min via nasal cannula? Select the best answer.

After completing post anesthesia recovery assessments, the registered nurse (RN) asks the practical nurse (PN) to transfer four clients, each two hours post-birth, to the postpartum unit. Which client should the PN ask the RN to reassess prior to transfer?

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

Patient Data. Exhibits The nurse has called the physician and is anticipating orders. Select the actions that would help with the listed treatment goals. Select all that apply.

Patient Data.

Exhibits

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