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 D

Explanation

A. A reduction in lump size and pain with oral contraceptives is expected and does not indicate a need to change the treatment plan.

B. Increased lump pain before menstruation is typical for fibrocystic changes and not a cause for concern.

C. Firm, movable lumps in the upper outer breast quadrants are characteristic of fibrocystic changes and do not suggest an alternative condition.

D. An area that is hot, pink, and tender indicates inflammation or possible infection (e.g., mastitis or abscess), requiring further evaluation and potentially altering the treatment plan.

A. Increase 0.9% Normal Saline infusion to 250 ml/hr per protocol. B. Collect blood cultures and start Vancomycin 1gm IV. C. Collect UA for culture and sensitivity. D. Administer Furosemide (Lasix) 20mg IV push.

Correct Answer is D

Explanation

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.

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

A 36-yr-old client who has a diagnosis of fibrocystic breast changes calls the nurse in the clinic reporting symptoms. Which information is likely to change the treatment plan?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

A nurse is reviewing the chart of a new client in the family medicine clinic and notes that the client is identified as "George Smith." The nurse enters the room and finds a woman in a skirt. What action by the nurse is best?

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

A client has just experienced a 90-second tonic-clonic seizure and has the following arterial blood gas results: pH 7.12, HCO3 22 mEq/L, PaCO2 55 mmHg, PaO2 60 mmHg. Which intervention is the most appropriate?

A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority?

A nurse leaves a coffee shop and sees a man lying on the ground. He is unresponsive and has no pulse and the nurse begins chest compressions. EMS arrives and connects the cardiac monitor displaying this rhythm. Identify the rhythm.

A client with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?