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A nurse is admitting a client from a provider's office.

Exhibits
Click to highlight the provider prescriptions the nurse should implement first.

  • Vital signs on admission and every 4 hr
  • NPO
  • Complete blood count
  • Basic metabolic profile
  • Arterial blood gases
  • Hemoccult stool
  • Stool culture and sensitivity
  • Urine culture and sensitivity
  • Sitz baths up to 3 times daily PRN

Medications:

  • Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hr
  • Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting
  • Ciprofloxacin 400 mg IV every 12 hr

A.

Vital signs on admission and every 4 hr

B.

NPO

C.

Complete blood count

D.

Basic metabolic profile

E.

Arterial blood gases

F.

Hemoccult stool

G.

Stool culture and sensitivity

H.

Urine culture and sensitivity

I.

Sitz baths up to 3 times daily PRN

J.

Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hr

K.

Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting

L.

Ciprofloxacin 400 mg IV every 12 hr

Answer and Explanation

The Correct Answer is ["A","B","J"]

Rationale

  • Vital signs on admission and every 4 hr → establish baseline and monitor for instability.
     
  • NPO → prevent worsening GI distress and prepare for possible procedures.
     
  • Dextrose 5% in 0.45% sodium chloride IV at 125 mL/hr → correct fluid volume deficit and dehydration.


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Related Questions

Correct Answer is B

Explanation

Rationale:
A. High fat content does not directly cause refeeding syndrome; fat is less likely to trigger the electrolyte shifts seen in this condition.

B. Rapid reintroduction of carbohydrates in malnourished patients stimulates insulin release, which drives phosphate, potassium, and magnesium into cells, leading to potentially life-threatening electrolyte imbalances—the hallmark of refeeding syndrome.

C. Excess protein intake can strain kidney function but is not the primary cause of refeeding syndrome.

D. Vitamin deficiencies, such as thiamine, can worsen complications, but the immediate trigger is the rapid carbohydrate load.

Correct Answer is C

Explanation

Rationale:
A. Baked potato is low in sodium if prepared without added salt, making it safe for a client on a diuretic.
B. Milkshake is generally safe unless it contains added sodium; in most cases, it is allowed.
C. Ham is high in sodium, which is contraindicated for a client taking bumetanide, a loop diuretic, as high sodium intake can counteract the diuretic effect and worsen fluid retention.
D. Stewed tomatoes can be included if unsalted; they are generally safe in moderation.

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