A nurse is admitting a client to a medical-surgical unit following a fall at home.

Exhibits

The nurse is discussing the client’s treatment plan with a provider. For each potential provider’s prescription, specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Administer spironolactone

Administer an IV fluid bolus

Obtain an x-ray of the right hip

Administer an iron supplement

Obtain the client’s weight

Administer supplemental oxygen

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Potential Prescription	Anticipated	Nonessential	Contraindicated
Administer spironolactone			✅
Administer an IV fluid bolus	✅
Obtain an x-ray of the right hip	✅
Administer an iron supplement		✅
Obtain the client’s weight	✅
Administer supplemental oxygen		✅

Choice A: Administer spironolactone

Spironolactone is a potassium-sparing diuretic used to manage heart failure and hypertension. However, the client’s potassium level is elevated at 5.3 mEq/L (normal range: 3.5 to 5 mEq/L) . Administering spironolactone could exacerbate hyperkalemia, leading to dangerous cardiac arrhythmias. Additionally, the client’s low blood pressure (89/60 mm Hg) and dehydration (indicated by dry skin and tenting) make the use of a diuretic inappropriate as it could further lower blood pressure and worsen dehydration .

Choice B: Administer an IV fluid bolus

The client presents with signs of dehydration (dry skin, tenting, low urine output) and hypotension (BP 89/60 mm Hg). An IV fluid bolus is anticipated to restore intravascular volume, improve blood pressure, and address

dehydration . This intervention is crucial to stabilize the client’s hemodynamic status and improve perfusion to vital organs .

Choice C: Obtain an x-ray of the right hip

The client reports pain in the right hip following a fall, which raises the suspicion of a fracture. An x-ray is essential to diagnose any potential fractures or dislocations, which are common in elderly patients after a fall 5.

Prompt imaging will guide appropriate management and prevent further complications .

Choice D: Administer an iron supplement

While the client has a history of iron-deficiency anemia and is on ferrous sulfate, the immediate need for iron supplementation is nonessential in the context of acute management of the fall and dehydration. The client’s hemoglobin (16 g/dL) and hematocrit (47%) are within normal ranges, indicating that anemia is currently well- managed . The focus should be on stabilizing the client’s acute condition.

Choice E: Obtain the client’s weight

Obtaining the client’s weight is anticipated as it is a critical parameter for calculating medication dosages, fluid requirements, and monitoring the client’s overall health status. Accurate weight measurement is particularly important in elderly patients with multiple comorbidities to ensure precise and safe medical management .

Choice F: Administer supplemental oxygen

The client’s oxygen saturation is 95% on room air, which is within the normal range (95-100%) . Therefore, administering supplemental oxygen is nonessential unless there is evidence of hypoxia or respiratory distress. The primary focus should be on addressing dehydration and hypotension.

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Correct Answer is A

Explanation

Choice A reason: Have you had a recent influenza infection?

Guillain-Barré syndrome (GBS) is often preceded by an infection, most commonly respiratory or gastrointestinal infections. Influenza is a significant respiratory infection that can trigger GBS. Asking about recent influenza infection helps in identifying a potential cause of the syndrome. According to the Mayo Clinic, many cases of GBS occur after a respiratory or gastrointestinal infection1. Therefore, this question is crucial in the assessment of a client with suspected GBS.

Choice B reason: Have you traveled overseas recently?

While travel history can be relevant in diagnosing various conditions, it is less directly related to Guillain-Barré syndrome. GBS is not typically associated with travel but rather with infections that can occur anywhere. Therefore, this question is less pertinent compared to asking about recent infections.

Choice C reason: Do you have a history of chronic alcohol abuse?

Chronic alcohol abuse can lead to various neurological conditions, but it is not specifically linked to Guillain-Barré syndrome. GBS is an acute condition often triggered by an infection, not by chronic alcohol use. Thus, while this question might be relevant in a broader neurological assessment, it is not directly related to GBS.

Choice D reason: Are you taking a multivitamin?

The use of multivitamins is generally not related to the development of Guillain-Barré syndrome. This question does not help in identifying the cause or confirming the diagnosis of GBS. It is more relevant to a general health assessment rather than a specific inquiry for GBS.

A. Ask the client to blow his nose. B. Suction the nostril. C. Notify the physician. D. Test the drainage for glucose.

Correct Answer is D

Explanation

Choice A reason: Ask the client to blow his nose

Asking the client to blow his nose is not advisable in this situation. Blowing the nose can increase intracranial pressure and potentially worsen the condition by causing more cerebrospinal fluid (CSF) to leak or even lead to further complications. Therefore, this action should be avoided.

Choice B reason: Suction the nostril

Suctioning the nostril is also not recommended. This action can introduce infection and increase the risk of further complications. It is important to handle any potential CSF leak with care to prevent infection and other issues.

Choice C reason: Notify the physician

While notifying the physician is important, it is not the immediate first step. The nurse should first confirm whether the clear drainage is CSF. Once confirmed, notifying the physician would be the next appropriate step.

Choice D reason: Test the drainage for glucose

Testing the drainage for glucose is the correct first action. CSF contains glucose, so a positive glucose test would confirm that the drainage is indeed CSF. This is a critical step in diagnosing a CSF leak, which can occur with basal skull fractures. Confirming the presence of CSF will guide further medical interventions and management.

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Choice B: Administer an IV fluid bolus

Choice C: Obtain an x-ray of the right hip

Choice D: Administer an iron supplement

Choice E: Obtain the client’s weight

Choice F: Administer supplemental oxygen

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (G85). Which of the following questions should the nurse ask the client?

Correct Answer is A

Explanation

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client’s right nostril. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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