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 ["B","E","G"]
Explanation
B. Position the patient with the head of the bed elevated. Rationale:
Promotes lung expansion: Elevating the head of the bed by at least 30 degrees utilizes gravity to assist in diaphragmatic descent and lung expansion. This allows for greater intake of air, optimizing oxygen intake and facilitating better gas exchange.
Reduces work of breathing: When upright, the abdominal muscles can more effectively aid in breathing, reducing the workload on the diaphragm and accessory muscles. This conserves energy and decreases the patient's respiratory effort.
Enhances secretion drainage: Gravity also aids in the movement of secretions from the lower lobes of the lungs towards the upper airways, where they can be more easily coughed up or suctioned. This helps to clear the airways and improve ventilation.
E. Teach the patient to cough at least once an hour. Rationale:
Clears secretions: Coughing is a natural mechanism to clear secretions from the lungs and airways. It helps to prevent mucus buildup and potential obstruction, which can lead to atelectasis (collapse of lung tissue) and further compromise ventilation.
Improves gas exchange: By removing secretions, coughing allows for better airflow and gas exchange within the lungs. This enhances oxygenation and helps to prevent respiratory complications.
G. Assist the patient in ambulating safely. Rationale:
Mobilizes secretions: Ambulation encourages movement of secretions from the lower lobes of the lungs, promoting their clearance and preventing mucus buildup.
Prevents atelectasis: Walking and movement help to expand the lungs, reducing the risk of atelectasis and improving overall ventilation.
Enhances circulation: Ambulation also improves circulation, which can help to deliver oxygen to the tissues more effectively and aid in healing.
Correct Answer is C
Explanation
Choice A rationale:
It is true that antibiotics are not effective against viruses like influenza. They only work against bacteria.
However, while providing this information to the client is accurate, it does not directly address the client's inquiry about taking oseltamivir, which is an antiviral medication.
It's essential for the nurse to guide the client toward the appropriate healthcare provider who can assess the client's condition and make an informed decision about whether oseltamivir is a suitable treatment option.
Choice B rationale:
While it is true that influenza vaccination is most effective when given before exposure to the virus, it is still a relevant consideration even after symptoms have begun.
Studies have shown that antiviral medications like oseltamivir can potentially reduce the severity and duration of influenza symptoms, even when started within 48 hours of symptom onset.
Therefore, simply advising the client that it's too late for vaccination without exploring other potential treatment options would be incomplete and potentially disadvantageous to the client's care.
Choice C rationale:
This is the most appropriate response because it ensures that the client receives a comprehensive assessment and individualized treatment plan from a qualified healthcare provider.
The provider can evaluate the client's symptoms, medical history, and potential risk factors to determine if oseltamivir is a suitable medication.
Additionally, the provider can discuss other potential treatment options, such as over-the-counter medications for symptom relief, and provide guidance on self-care measures to promote recovery.
Choice D rationale:
While over-the-counter medications can help manage some symptoms of influenza, such as fever, aches, and cough, they do not directly target the virus itself.
Antiviral medications like oseltamivir can potentially shorten the duration of the illness and reduce the risk of complications, especially in individuals at higher risk.
Therefore, relying solely on over-the-counter medications without considering antiviral therapy could potentially delay recovery and increase the likelihood of adverse outcomes.
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