A nurse is caring for a male client who reports abdominal pain.
Change IV fluids to 0.9 % sodium chloride with 20 KCL @ 125 mL/hr.
CT of the abdomen with contrast.
Type and cross match blood.
Administer ampicillin/sulbactam IV bolus.
Request a diet high in fiber
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Order 1: Change IV fluids to 0.9% sodium chloride with 20 KCl @ 125 mL/hr.
Anticipated: The client has hypokalemia (K+ decreased to 3.2 mEq/L on Day 2), which requires correction to prevent complications like cardiac arrhythmias. Adding potassium chloride (KCl) to the IV fluids and increasing the infusion rate addresses dehydration and electrolyte imbalance.
Order 2: CT of the abdomen with contrast.
Contraindicated: The client has elevated creatinine levels on Day 1 (1.1 mg/dL, borderline for kidney function). Although it improved by Day 2 (0.9 mg/dL), administering IV contrast can still pose a risk of nephrotoxicity, particularly in a patient with potential dehydration and borderline renal function. An abdominal CT scan without contrast is preferred in this situation.
Order 3: Type and crossmatch blood.
Anticipated: The client's hemoglobin and hematocrit are significantly decreased (Hb dropped from 12 g/dL to 11 g/dL, and Hct from 37% to 30%), indicating possible ongoing blood loss (positive stool occult blood and worsening anemia). Typing and crossmatching blood prepare for a transfusion if necessary.
Order 4: Administer ampicillin/sulbactam IV bolus.
Contraindicated: The client has a documented allergy to penicillin, and ampicillin/sulbactam is a penicillin-class antibiotic. Administering it could trigger an allergic reaction.
Order 5: Request a diet high in fiber.
Contraindicated: A high-fiber diet is contraindicated in acute diverticulitis due to the risk of worsening intestinal irritation and obstruction. The client is also currently NPO due to nausea, vomiting, and suspected complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer sodium biphosphate/sodium phosphate enema: Enemas are contraindicated in suspected appendicitis as they can increase the risk of rupture due to increased pressure in the bowel.
B. Maintain NPO status: Keeping the client NPO is appropriate to prepare for potential surgery.
C. Medicate the client for pain every 4 hr as needed: Pain medication is appropriate and does not mask significant clinical findings in appendicitis.
D. Monitor oral temperature every 4 hr: Monitoring temperature helps detect signs of infection or worsening inflammation, such as rupture or peritonitis.
Correct Answer is C
Explanation
A. 3% sodium chloride: This hypertonic saline is used for severe hyponatremia and is inappropriate for TPN replacement.
B. 0.9% sodium chloride: Normal saline lacks the glucose content needed to prevent hypoglycemia when TPN is abruptly stopped.
C. Dextrose 10% in water: This solution provides glucose to prevent hypoglycemia, which can occur if TPN is suddenly discontinued.
D. Lactated Ringer's: Lactated Ringer's is used for fluid and electrolyte replacement but does not provide sufficient glucose for TPN interruption.
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