75-year-old who lives alone, is admitted to the hospital because of weakness and confusion.

Physical Examination

Confusion, slow to respond to questioning, generalized weakness, decreased skin turgor, dry mucous membranes, peripheral pulses weak.

Vitals: T: 101 F, BP 90/62, HR 120 bpm and irregular, RR 24, Sp02 89% on room air.

Central Venous Pressure (CVP): 1 mmHg

Pulmonary Arterial Wedge Pressure (PAWP): 2 mmHg.

Test Name

Results

Reference Range

WBC

12, 000

4, 000- 11, 000

Na+

149 mEq/L

135-145 mEq/L

K+

5.0 mEq/L

3.5- 5.0 mEq/L

Cl-

110 mEq/L

96-106 mEq/L

pH

7.34

7.35-7.45

PaCO2

34 mmHg

35- 45 mmHg

PaO2

78 mm Hg

80-100 mmHg

HCO3

21 mEq/L

22- 26 mEq/L

What order by the health care provider should the nurse question?

Increase 0.9% Normal Saline infusion to 250 ml/hr per protocol.

Collect blood cultures and start Vancomycin 1gm IV.

Collect UA for culture and sensitivity.

Administer Furosemide (Lasix) 20mg IV push.

Answer and Explanation

The Correct Answer is D

A. Increasing normal saline infusion is appropriate for treating dehydration and hypovolemia.

B. Collecting blood cultures and administering antibiotics is appropriate for treating possible sepsis, given the fever and elevated WBC count.

C. Collecting a urine sample for culture and sensitivity is appropriate to investigate a potential urinary source of infection.

D. Administering furosemide, a diuretic, is inappropriate in a client with signs of dehydration and hypovolemia (e.g., low CVP and PAWP) as it can worsen fluid depletion.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "I will make sure that my partner takes all the prescribed medication.": This is the correct answer. Expedited partner therapy involves treating the partner(s) without an initial clinical visit, so ensuring they take all prescribed medications is essential to prevent reinfection.

B. "I will have my partner take the antibiotics if any STI symptoms occur.": This is incorrect because the partner should take the antibiotics regardless of symptoms to effectively treat the infection.

C. "I will have my partner use a condom until I finish the antibiotics.": While condom use is important, it does not replace the need for the partner to receive treatment.

D. "I will tell my partner that it is important to be examined at the clinic.": Although important, expedited partner therapy aims to provide treatment without a clinic visit.

A. Client with a blood pressure of 90/50 mm Hg. B. Client with a temperature of 96° F (35.6° C). C. Client with a pulse of 118 beats/min. D. Client with a respiratory rate of 6 breaths/min.

Correct Answer is D

Explanation

A. A blood pressure of 90/50 mm Hg is concerning, but it is less urgent than severe respiratory depression. The nurse should still assess this client promptly.

B. A temperature of 96° F (35.6° C) is mildly low and should be addressed, but it is not as critical as a severely low respiratory rate.

C. A pulse of 118 beats/min is elevated and may require monitoring, but it does not pose as immediate a threat as respiratory depression.

D. A respiratory rate of 6 breaths/min is critically low, which may indicate respiratory depression, particularly after anesthesia. Immediate assessment and intervention are needed to ensure adequate oxygenation and ventilation.

View Question and Answer

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Test Name	Results	Reference Range
WBC	12, 000	4, 000- 11, 000
Na+	149 mEq/L	135-145 mEq/L
K+	5.0 mEq/L	3.5- 5.0 mEq/L
Cl-	110 mEq/L	96-106 mEq/L
pH	7.34	7.35-7.45
PaCO2	34 mmHg	35- 45 mmHg
PaO2	78 mm Hg	80-100 mmHg
HCO3	21 mEq/L	22- 26 mEq/L

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After the nurse has taught the client with a newly diagnosed sexually transmitted infection about expedited partner therapy, which client statement indicates that teaching has been effective?

Correct Answer is A

Explanation

The post anesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client would the nurse assess first?

Correct Answer is D

Explanation

The nurse in the women's health clinic has four clients who are waiting to be seen. Which client should the nurse see first?

After reviewing the client's chart upon admission to the unit, the nurse consults the healthcare provider about a new order for lovastatin (Mevacor). What triggered the nurse's action?

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

After starting the treatment for type 2 diabetes mellitus 6 months earlier, a client is in the office for a follow-up examination. The nurse will monitor which laboratory test to evaluate the clients adherence to the antidiabetic therapy over the past few months?

The nurse is providing preoperative education to a client prior to having an orchiectomy for testicular cancer. What statement by the client indicates the need to review the information?

A client who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine levels. Which prescribed therapy should the nurse implement first?

Which information about continuous bladder irrigation will the nurse teach to a client who is being admitted for a transurethral resection of the prostate (TURP)?