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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: Auscultating bowel sounds and measuring abdominal girth are not directly related to the management of erosive esophagitis and GERD symptoms. These actions are more pertinent to assessing gastrointestinal motility and distension, not the effectiveness of lansoprazole.
Choice B rationale: Lansoprazole is a proton pump inhibitor that should be taken before meals to reduce stomach acid production effectively. Confirming that the patient is taking the medication before meals could help optimize its efficacy but is not the most immediate step.
Choice C rationale: Notifying the healthcare provider about a potential need for a dosage change may be considered if symptoms persist. However, since healing with proton pump inhibitors can take several weeks, this action may be premature after only one week of use.
Choice D rationale: It is appropriate to inform the patient that healing of erosive esophagitis and symptom relief from GERD can take several weeks with lansoprazole. This education helps set realistic expectations and encourages adherence to the prescribed treatment.
Correct Answer is B
Explanation
Choice A rationale:
Colloidal oatmeal-based lotion: While colloidal oatmeal can soothe and moisturize dry, itchy skin, it does not have the anti- inflammatory properties necessary to effectively treat the underlying inflammation of psoriasis.
It may provide temporary relief of symptoms, but it won't address the root cause of the condition.
Choice B rationale:
Topical corticosteroids: These medications are the mainstay of treatment for psoriasis. They work by reducing inflammation and slowing the growth of skin cells.
Topical corticosteroids come in a variety of strengths and formulations, including creams, ointments, gels, lotions, and sprays. The choice of formulation will depend on the severity of the psoriasis, the location of the lesions, and the patient's preferences. Choice C rationale:
Topical analgesics: Topical analgesics, such as lidocaine or benzocaine, can help to relieve pain and itching associated with psoriasis.
However, they do not address the underlying inflammation and are not a long-term solution for managing the condition. They are typically used as adjunctive therapy, in conjunction with other psoriasis treatments.
Choice D rationale:
Topical antifungals: Topical antifungal medications are used to treat fungal infections, such as ringworm and athlete's foot. They are not effective in treating psoriasis, which is an autoimmune condition, not a fungal infection.
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