The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

Urine output of 30 mL/hr

Blood pressure is 90/40

IV site is infiltrated

Oral fluid intake of 100 mL for 8 hours

Answer and Explanation

The Correct Answer is B

Choice A reason: Urine output of 30 mL/hr is concerning as it is on the lower end of normal and can indicate dehydration or impaired renal function. However, in this context, it is less immediately alarming compared to severely low blood pressure.

Choice B reason: Blood pressure of 90/40 is critically low and indicates hypotension, which can be a sign of severe dehydration or shock, especially in a patient with ongoing nausea and vomiting. This requires immediate attention and intervention to stabilize the patient and prevent further complications.

Choice C reason: An infiltrated IV site is a problem that needs to be addressed to ensure proper administration of fluids and medications. However, it is not as immediately life-threatening as hypotension.

Choice D reason: Oral fluid intake of 100 mL for 8 hours is inadequate, suggesting that the patient may be dehydrated. While concerning, it is not as acutely critical as low blood pressure, which directly affects perfusion and organ function.

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Correct Answer is D

Explanation

Choice A reason: Anticipating obtaining a throat swab for rapid streptococcus testing is not immediately related to the use of a budesonide inhaler. This test is typically done when there is a suspicion of a streptococcal infection, not specifically for managing asthma medication side effects.

Choice B reason: Offering reassurance that the symptoms are common with budesonide use may not fully address the patient’s concern or prevent potential complications. It is more effective to provide actionable advice that can help manage the symptoms.

Choice C reason: Suggesting that the patient stop using the spray until the symptoms are resolved could potentially worsen asthma control. Budesonide is an important medication for managing asthma, and discontinuing it without alternative treatment may lead to exacerbation of symptoms.

Choice D reason: Teaching the patient to gargle with water after using the budesonide inhaler is the most appropriate action. This practice helps to reduce the risk of developing oral thrush, a common side effect of inhaled corticosteroids like budesonide. Gargling with water removes any residual medication in the mouth, thereby minimizing the risk of infection.

A. Subcutaneous administration of Lovenox or heparin B. Graduated compression stockings (e.g., thromboembolic deterrent [TED] hose) C. Intermittent pneumatic compression devices (IPCs) D. Strict bed rest E. Early and aggressive mobilization

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

Explanation

Choice A reason: Subcutaneous administration of anticoagulants like Lovenox (enoxaparin) or heparin is a common and effective method for preventing DVT and VTE. These medications help prevent clot formation by thinning the blood and reducing the risk of thrombus development.

Choice B reason: Graduated compression stockings, such as thromboembolic deterrent (TED) hose, are used to improve blood flow in the legs and prevent the formation of blood clots. They apply consistent pressure to the legs, helping to maintain venous return and reduce the risk of DVT.

Choice C reason: Intermittent pneumatic compression devices (IPCs) are also used to prevent DVT and VTE. These devices periodically inflate and deflate, applying pressure to the legs to stimulate blood flow and prevent blood stasis, which can lead to clot formation.

Choice D reason: Strict bed rest is not recommended for DVT and VTE prevention. Prolonged immobility can increase the risk of clot formation. Encouraging early mobilization and activity is crucial to reduce the risk of DVT.

Choice E reason: Early and aggressive mobilization is a key strategy in preventing DVT and VTE. Encouraging patients to move and engage in physical activity as soon as it is safe to do so helps promote blood circulation and prevent the development of blood clots.

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The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a patient with asthma who is on a budesonide hand-held inhaler reports difficulty, what should the nurse do?

Correct Answer is D

Explanation

Deep vein thrombosis (DVT) and venous thromboembolism (VTE) prevention methods include which of the following? Select all that apply.

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

Explanation

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