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 D
Explanation
Choice A reason: Sliced ham with green salad is not a good choice for a client who has diverticulitis. Diverticulitis is a condition where small pouches in the colon become inflamed or infected. The client should avoid foods that are high in fat, such as ham, or that contain seeds, nuts, or skins, such as green salad, as they can irritate the colon and worsen the symptoms.
Choice B reason: Pork tenderloin with green peas is not a suitable choice for a client who has diverticulitis. Pork tenderloin is a high-fat food that can increase the inflammation and pain in the colon. Green peas are also a source of fiber that can be hard to digest and can cause gas and bloating.
Choice C reason: Turkey sandwich with celery sticks is not an appropriate choice for a client who has diverticulitis. Turkey sandwich may contain mayonnaise, cheese, or other ingredients that are high in fat and can aggravate the condition. Celery sticks are high in fiber and have strings that can get trapped in the pouches and cause infection.
Choice D reason: Grilled chicken breast with white bread is the best choice for a client who has diverticulitis. Grilled chicken breast is a lean protein that can help the client heal and prevent malnutrition. White bread is a low-fiber food that can be easily digested and does not irritate the colon.
Correct Answer is B
Explanation
Choice A reason: This is not a correct manifestation of appendiceal perforation. Blanched abdomen means that the skin of the abdomen is pale or white, which can indicate shock or blood loss. However, it is not a specific sign of appendiceal perforation, as it can occur in other conditions as well.
Choice B reason: This is a correct manifestation of appendiceal perforation. Sudden decrease in abdominal pain means that the pain that was previously felt in the right lower quadrant of the abdomen has subsided or disappeared. This can indicate that the appendix has ruptured and released the pus and bacteria into the peritoneal cavity, causing peritonitis. This is a serious complication that requires immediate surgical intervention.
Choice C reason: This is not a correct manifestation of appendiceal perforation. Absent Rovsing's sign means that there is no pain in the right lower quadrant of the abdomen when the left lower quadrant is palpated. This is a sign of appendicitis, not appendiceal perforation, as it indicates that the appendix is inflamed and irritated by the pressure.
Choice D reason: This is not a correct manifestation of appendiceal perforation. Fever means that the body temperature is above the normal range, which can indicate infection or inflammation. However, it is not a specific sign of appendiceal perforation, as it can occur in other conditions as well.
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