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The nurse is caring for a client.

Which of the following 4 orders or prescriptions should the nurse anticipate?
Select the 4 orders or prescriptions that the nurse should anticipate.

Obtain a brain natriuretic peptide (BNP) test.

Obtain a complete blood count.

Request respiratory therapy for intubation.

Obtain a STAT MRI.

Obtain ABGs.

Prepare the client for cardiac catheterization.

Obtain a chest x-ray.

Answer and Explanation

Correct Answer : A,B,E,G

A. Obtain a brain natriuretic peptide (BNP) test: BNP is a marker of heart failure and is indicated given the client’s new-onset dyspnea, crackles, and S3/S4 heart sounds. Measuring BNP helps assess for possible acute decompensated heart failure following surgery.

B. Obtain a complete blood count: A CBC helps identify infection, anemia, or other hematologic changes that could contribute to dyspnea, tachypnea, or hypoxia in the postoperative client. The client’s fever and tachycardia warrant this assessment.

C. Request respiratory therapy for intubation: Intubation is not immediately indicated as the client is still alert, maintaining oxygen saturation of 92% on supplemental oxygen. Less invasive diagnostics and interventions are prioritized first.

D. Obtain a STAT MRI: MRI is not the first-line diagnostic tool for acute dyspnea and postoperative cardiopulmonary assessment. It is not indicated in emergent evaluation of pulmonary or cardiac complications.

E. Obtain ABGs: Arterial blood gases are important to assess oxygenation, ventilation, and acid-base status given the client’s tachypnea, hypoxemia, and sudden respiratory distress.

F. Prepare the client for cardiac catheterization: Cardiac catheterization is invasive and not the immediate priority. Initial noninvasive assessment should guide the need for further intervention.

G. Obtain a chest x-ray: A chest x-ray is indicated to assess for pulmonary edema, pleural effusion, or other cardiopulmonary complications in a postoperative client presenting with dyspnea, crackles, and hypoxia.

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

Explanation

A. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to navigate their environment and complete activities safely. Providing extra time reduces stress, supports independence, and promotes a sense of autonomy while performing daily tasks.

B. Touch the client gently to announce presence: The nurse should announce presence verbally first. Touching without warning may startle the client.

C. Keep objects in the client's room in the same place: Maintaining a consistent arrangement of personal items prevents confusion and reduces the risk of falls or accidents. Predictable placement allows the client to perform tasks safely and maintain independence.

D. Approach the client from the side: Approaching from the side is not recommended because it may startle the client. Best practice is to approach from the front while using verbal cues to announce your presence and provide orientation.

E. Ensure there is high-wattage lighting in the client's room: High-intensity lighting may cause glare and discomfort for clients with vision loss, especially those with conditions like macular degeneration. Adequate but non-glare lighting is preferable to support safe mobility.

A. Thrombocytopenia B. Hypothermia C. Maternal diabetes D. Prematurity E. Anemia

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

Explanation

Rationale:

A. Thrombocytopenia: Low platelet count is not a recognized risk factor for neonatal hypoglycemia. While it may indicate other hematologic concerns, it does not directly affect the infant’s glucose regulation.

B. Hypothermia: Hypothermia increases metabolic demand and glucose consumption in newborns, making them more susceptible to hypoglycemia. Maintaining neutral thermal environment is crucial to reduce this risk.

C. Maternal diabetes: Infants of mothers with diabetes are at increased risk for hypoglycemia due to fetal hyperinsulinemia. After birth, the high insulin levels can cause a rapid drop in blood glucose.

D. Prematurity: Premature infants have limited glycogen stores, immature liver function, and impaired gluconeogenesis, all of which increase the risk of hypoglycemia. Monitoring and early feeding are essential.

E. Anemia: While anemia can affect oxygen delivery, it is not a direct risk factor for hypoglycemia in the newborn. It may complicate overall neonatal status but does not independently cause low blood glucose.

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The nurse is caring for a client. Which of the following 4 orders or prescriptions should the nurse anticipate? Select the 4 orders or prescriptions that the nurse should anticipate.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

A charge nurse in a newborn nursery is providing information to a group of nurses about risk factors for hypoglycemia. Which of the following risk factors should the charge nurse include? (Select all that apply.)

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

Explanation

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The nurse is caring for a client.

Which of the following 4 orders or prescriptions should the nurse anticipate?
Select the 4 orders or prescriptions that the nurse should anticipate.