A nurse is caring for an adult client who has a fever of 39.4°C (103°F) and is receiving 0.9% sodium chloride IV at 125 mL/hr. Over the last hour, the nurse notes that the client's urine output is 20 mL. The nurse should report this finding to the provider and anticipate a prescription for what?
An antipyretic medication
A diuretic medication
A blood culture
A fluid bolus
The Correct Answer is D
Choice A reason: An antipyretic medication is not the best answer because it does not address the client's low urine output. An antipyretic medication is a drug that lowers the body temperature by reducing the production of heat or increasing the loss of heat. It may help the client feel more comfortable, but it does not improve the kidney function or prevent dehydration.
Choice B reason: A diuretic medication is not the best answer because it may worsen the client's low urine output. A diuretic medication is a drug that increases the excretion of water and electrolytes by the kidneys. It may lower the blood pressure and reduce the fluid overload, but it may also cause dehydration, electrolyte imbalance, and kidney damage.
Choice C reason: A blood culture is not the best answer because it does not address the client's low urine output. A blood culture is a laboratory test that detects the presence of bacteria or other microorganisms in the blood. It may help identify the cause of the fever and guide the antibiotic therapy, but it does not improve the kidney function or prevent dehydration.
Choice D reason: A fluid bolus is the best answer because it may improve the client's low urine output. A fluid bolus is a rapid infusion of a large volume of fluid, usually isotonic saline or lactated Ringer's solution. It may increase the blood volume and pressure, improve the tissue perfusion, and stimulate the urine production. It may also help lower the fever by diluting the pyrogens and increasing the heat loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not a correct instruction because drinking a carbonated beverage before bed can worsen the reflux symptoms by increasing the gastric pressure and the production of gas.
Choice B reason: This is not a correct instruction because increasing fatty foods can worsen the reflux symptoms by delaying the gastric emptying and relaxing the lower esophageal sphincter (LES), which allows the stomach acid to flow back into the esophagus.
Choice C reason: This is a correct instruction because elevating the head of the bed when sleeping can help prevent the reflux symptoms by using gravity to keep the stomach contents from flowing back into the esophagus.
Choice D reason: This is not a correct instruction because eating dinner late in the evening can worsen the reflux symptoms by increasing the amount and acidity of the stomach contents, which can easily flow back into the esophagus when lying down. The client should avoid eating within 3 hours of bedtime.
Correct Answer is A
Explanation
Choice A reason: Fried cheese is a food that the nurse will question on the tray for a client with acute gallbladder inflammation. Fried cheese is high in fat, which can trigger or worsen the symptoms of gallbladder disease. Fat can stimulate the contraction of the gallbladder, which can cause pain and inflammation if there are gallstones blocking the bile ducts.
Choice B reason: Green beans are not a food that the nurse will question on the tray for a client with acute gallbladder inflammation. Green beans are low in fat and high in fiber, which can help prevent or reduce the symptoms of gallbladder disease. Fiber can help lower the cholesterol levels in the bile, which can reduce the risk of gallstone formation.
Choice C reason: Grilled chicken breast is not a food that the nurse will question on the tray for a client with acute gallbladder inflammation. Grilled chicken breast is a lean protein source, which can provide essential amino acids for the client's health. Protein can also help maintain the muscle mass and strength of the client, who may have reduced appetite and weight loss due to gallbladder disease.
Choice D reason: Whole grain dinner roll is not a food that the nurse will question on the tray for a client with acute gallbladder inflammation. Whole grain dinner roll is a complex carbohydrate source, which can provide energy and fiber for the client. Carbohydrates can also help balance the acid-base status of the client, who may have metabolic acidosis due to impaired bile secretion and digestion.
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