A nurse is caring for an oldest patient.

Exhibits

For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Ice packs to affected area 15 minutes on, 15 minutes off

Intravenous fluids (IVF) at maintenance rate

Ketorolac IV for pain

Ambulate in hallway with supervision

Meperidine IV for pain

Answer and Explanation

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

Choice A: Ice packs to affected area 15 minutes on, 15 minutes off

Reason: Ice packs are generally contraindicated for patients with sickle cell disease (SCD). The use of ice packs can cause vasoconstriction, which narrows blood vessels and reduces blood flow. This can exacerbate the pain and potentially trigger a vaso-occlusive crisis (VOC) by further restricting blood flow to the already compromised areas. Studies have shown that cold exposure can worsen pain in SCD patients, making ice packs an unsuitable option.

Choice B: Intravenous fluids (IVF) at maintenance rate

Reason: Intravenous fluids are anticipated for patients with SCD, especially during a pain crisis. Hydration is crucial as it helps to reduce the viscosity of the blood, thereby improving blood flow and reducing the likelihood of sickling. Adequate hydration can help to alleviate pain and prevent further complications. The administration of IV fluids is a standard practice in managing acute pain episodes in SCD patients.

Choice C: Ketorolac IV for pain

Reason: Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID), is anticipated for managing pain in SCD patients. It provides effective pain relief without the risks associated with opioids, such as respiratory depression and dependence. Ketorolac works by inhibiting the production of prostaglandins, which are involved in the inflammatory process and pain signaling. It is particularly useful for acute pain management in SCD patients.

Choice D: Ambulate in hallway with supervision

Reason: Ambulation during a pain crisis is generally contraindicated for SCD patients. Movement can increase pain and stress on the affected areas, potentially worsening the condition. During a VOC, patients are often advised to rest and avoid activities that could exacerbate the pain. While physical activity is important for overall health, it should be carefully managed and avoided during acute pain episodes.

Choice E: Meperidine IV for pain

Reason: Meperidine is contraindicated for pain management in SCD patients due to its potential for serious side effects. Meperidine can accumulate in the body and produce a toxic metabolite called normeperidine, which can cause seizures and other adverse effects. Additionally, meperidine is less effective than other opioids and has a higher risk of causing dependency and other complications. Therefore, it is not recommended for managing pain in SCD patients.

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Correct Answer is B

Explanation

Choice A reason:

Supported Sims: The Supported Sims position involves lying on one side with the lower arm behind the back and the upper thigh flexed. This position is not typically recommended for postoperative cholecystectomy patients as it does not provide optimal support for breathing and comfort.

Choice B reason:

Semi-Fowler’s: The Semi-Fowler’s position, where the head of the bed is elevated to about 30-45 degrees, is ideal for postoperative cholecystectomy patients. This position helps facilitate breathing, reduces the risk of aspiration, and promotes comfort by reducing tension on the abdominal muscles.

Choice C reason:

Dorsal recumbent: The Dorsal recumbent position involves lying flat on the back with knees bent and feet flat on the bed. While this position can be used for certain procedures, it is not the most comfortable or beneficial for postoperative cholecystectomy patients as it can increase abdominal pressure and discomfort.

Choice D reason:

Prone: The Prone position, where the patient lies flat on their stomach, is not suitable for postoperative cholecystectomy patients. This position can cause discomfort and does not support optimal breathing or reduce abdominal tension.

A. Obtain a 12-lead ECG. B. Suggest that the client use a salt substitute. C. Advise the client to add citrus juices and bananas to her diet. D. Obtain a blood sample for a serum sodium level.

Correct Answer is A

Explanation

Choice A reason: Obtain a 12-lead ECG

Obtaining a 12-lead ECG is a critical action when a client has a potassium level of 6.8 mEq/L, which indicates hyperkalemia. Hyperkalemia can cause serious cardiac dysrhythmias, including life-threatening arrhythmias such as ventricular fibrillation or asystole. An ECG can help detect these abnormalities early, allowing for prompt intervention to prevent cardiac complications. The ECG may show characteristic changes such as peaked T waves, widened QRS complexes, and prolonged PR intervals, which are indicative of hyperkalemia.

Choice B reason: Suggest that the client use a salt substitute

Suggesting that the client use a salt substitute is not appropriate in this situation. Many salt substitutes contain potassium chloride, which can further increase the potassium level in the blood. For a client with hyperkalemia, it is crucial to avoid additional sources of potassium to prevent exacerbating the condition. Therefore, recommending a salt substitute could be harmful.

Choice C reason: Advise the client to add citrus juices and bananas to her diet

Advising the client to add citrus juices and bananas to her diet is also inappropriate. Both citrus juices and bananas are high in potassium and can contribute to an increase in serum potassium levels. For a client with hyperkalemia, it is essential to limit dietary potassium intake to help lower the potassium levels in the blood. Encouraging the consumption of high-potassium foods would be counterproductive and potentially dangerous.

Choice D reason: Obtain a blood sample for a serum sodium level

While obtaining a blood sample for a serum sodium level can be part of a comprehensive assessment, it is not the immediate priority in managing hyperkalemia. The primary concern with a potassium level of 6.8 mEq/L is the risk of cardiac dysrhythmias. Therefore, obtaining an ECG to monitor the heart’s electrical activity is the most urgent and appropriate action. Once the immediate risk is addressed, further laboratory tests, including serum sodium levels, can be conducted as part of the overall assessment and management plan.

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A nurse is caring for an oldest patient. Exhibits For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client?

Correct Answer is B

Explanation

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

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A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare the protocol based on which of the following information? (Select all that apply.)

A nurse is caring for an oldest patient.

Exhibits

For each potential provider’s prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.