A patient's data shows the following: Oxygen saturation is 94% on room air, pain is 4 on a scale of 0 to 10, temperature is 99.6°F (37.6°C) orally, and heart rate is 95 beats/minute.
Which physician orders would the nurse anticipate being prescribed after reporting these findings? Select all that apply.
Place client on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
Stat ventilation/perfusion (V/Q) of chest.
Stat 2 views chest x-ray.
Stat Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.
Send sputum for culture & sensitivity.
Correct Answer : A,C,D
The correct answer is choice A, C, and D.
Choice A rationale:
The patient’s oxygen saturation is at 94%, which is just below the normal range of 95-100% for healthy adults breathing room air. Administering oxygen 2 to 4 liters to maintain oxygen saturation at or above 95% is a standard intervention to ensure adequate oxygenation.
Choice B rationale:
A stat ventilation/perfusion (V/Q) scan is typically ordered for suspected pulmonary embolism, which is not indicated by the patient’s current data. The patient’s symptoms do not specifically suggest a V/Q mismatch that would necessitate this diagnostic test.
Choice C rationale:
A chest x-ray is a common diagnostic tool for evaluating the lungs and heart, especially when a patient presents with symptoms that may indicate respiratory or cardiac issues. Given the patient’s temperature and heart rate, which are slightly elevated, a chest x-ray can help identify any potential underlying conditions.
Choice D rationale:
Ordering a CBC, BMP, and blood cultures can help identify the cause of the patient’s fever and tachycardia. These tests provide valuable information about the patient’s immune response, electrolyte balance, kidney function, and whether there is a bacterial infection.
Choice E rationale:
While sending sputum for culture and sensitivity could be helpful if a respiratory infection is suspected, the patient’s data does not strongly indicate a respiratory infection as the primary issue. Therefore, this test may not be the most immediate need.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Autoimmune responses occur when the immune system mistakenly attacks the body's own tissues. They are not typically triggered by allergens like bee stings.
Autoimmune responses often develop slowly over time and present with symptoms related to the specific tissues being attacked.
The rapid onset of symptoms in this case, along with the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of an autoimmune response.
Choice B rationale:
Type II hypersensitivity reactions involve antibodies that target and destroy cells or tissues. These reactions often take hours or days to develop, rather than minutes.
Examples of type II hypersensitivity reactions include transfusion reactions, hemolytic disease of the newborn, and some autoimmune diseases.
The rapid onset of symptoms in this case is not consistent with a type II hypersensitivity reaction.
Choice C rationale:
Cell-mediated hypersensitivity reactions involve T cells that directly attack cells or tissues. These reactions typically take 1-3 days to develop.
Examples of cell-mediated hypersensitivity reactions include contact dermatitis (e.g., poison ivy), graft-versus-host disease, and some drug reactions.
The rapid onset of symptoms in this case, as well as the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of a cell-mediated hypersensitivity reaction.
Choice D rationale:
IgE response hypersensitivity reactions are the most immediate type of allergic reaction.
They are mediated by immunoglobulin E (IgE) antibodies, which bind to mast cells and basophils.
When an allergen (like bee venom) cross-links IgE antibodies on mast cells, it triggers the release of histamine and other inflammatory mediators.
These mediators cause vasodilation, increased vascular permeability, smooth muscle contraction, and mucus secretion, leading to the characteristic symptoms of an allergic reaction.
The rapid onset of symptoms in this case, including rash, shortness of breath, and low blood pressure, are consistent with an IgE-mediated hypersensitivity reaction.
Correct Answer is A
Explanation
Choice A rationale:
Hemoglobin A1C (HbA1C) is a blood test that reflects a person's average blood glucose levels over the past 2-3 months. It's considered the gold standard for diagnosing and monitoring diabetes.
An HbA1C level of 8.29% is significantly elevated above the reference range of 4-5.99%, indicating a high probability of diabetes.
The patient's HbA1C has also increased from 7.59% three months ago, suggesting a worsening of glycemic control.
Diabetes mellitus is a chronic metabolic disorder characterized by elevated blood glucose levels due to impaired insulin production or action, or both.
Common symptoms of diabetes include increased thirst, frequent urination, fatigue, blurred vision, and slow-healing wounds.
Early diagnosis and treatment of diabetes are crucial to prevent complications such as heart disease, stroke, kidney disease, nerve damage, and vision loss.
Choice B rationale:
Hypoglycemia refers to abnormally low blood glucose levels, typically below 70 mg/dL. It's often caused by excessive insulin or medication, missed meals, or strenuous exercise.
The patient's HbA1C level of 8.29% does not support a diagnosis of hypoglycemia.
Choice C rationale:
Hyperglycemia refers to abnormally high blood glucose levels, typically above 180 mg/dL. It can be caused by diabetes, stress, infection, or certain medications.
While the patient's HbA1C level does indicate hyperglycemia, it's specifically the pattern of elevated HbA1C over time that points to a diagnosis of diabetes mellitus, rather than transient hyperglycemia.
Choice D rationale:
Prediabetes is a condition where blood glucose levels are higher than normal, but not high enough to be classified as diabetes. People with prediabetes are at increased risk of developing diabetes.
The patient's HbA1C level of 8.29% is above the threshold for prediabetes, which is typically 5.7-6.4%.
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