The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400.
For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.
Administer acyclovir.
Administer lorazepam.
Initiate 1:1 supervision.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
| Potential Provider Prescription | Expected or Unexpected? | Explanation |
|---|---|---|
| Administer acyclovir. | Unexpected | Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause. |
| Administer lorazepam. | Expected | Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention. |
| Initiate 1:1 supervision. | Expected | The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety. |
| Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion. | Expected | The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration. |
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F","G"]
Explanation
The findings that require immediate follow-up are: Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly. Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. Aripiprazole is an antipsychotic medication and is not used for smoking cessation.
Choice B rationale:
This statement is correct. Bupropion is an antidepressant that has been shown to be effective in helping people quit smoking.
Choice C rationale:
This statement is incorrect. Quetiapine is an antipsychotic medication and is not used for smoking cessation.
Choice D rationale:
This statement is incorrect. Risperidone is an antipsychotic medication and is not used for smoking cessation.
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