An adult is admitted with acute flank pain, a 102° F (38.9° C) oral temperature, hematuria, dysuria, urgency, and fishy-smelling urine. Which admitting prescription(s) are most important for the nurse to implement? Select all that apply.
Give diphenhydramine prep for intravenous pyelogram.
Obtain clean catch urine for culture and sensitivity.
Force oral fluids to 2,000 mL/24 hours.
Initiate broad spectrum IV antibiotic as secondary infusion.
Collect a serum sample for hemoglobin and hematocrit.
Correct Answer : B,D
A. Diphenhydramine is unnecessary for diagnosing pyelonephritis.
B. Urine culture confirms bacterial infection and guides antibiotic therapy.
C. Forcing fluids may help but is not the priority over antibiotics and cultures.
D. Broad-spectrum IV antibiotics are critical to treat systemic infection.
E. Hemoglobin and hematocrit are not priority tests for pyelonephritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cerebral palsy is caused by brain injury or abnormal development, but the damage itself does not worsen over time. The severity of symptoms can vary as the child grows, but it is not progressive.
B. While CP is a permanent disability, this response does not address the client’s concern about the progression of symptoms.
C. The brain lesion in CP does not continue to develop in most cases, so this explanation would not provide accurate information.
D. Severe motor dysfunction does not solely determine the child’s outcome, as therapy and early interventions can significantly improve functional abilities.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"D"},"F":{"answers":"C"},"G":{"answers":"D"}}
Explanation
Blood pressure 112/77 mmHg: Indicates adequate perfusion and stabilized blood pressure, which is a sign of successful hypovolemia management after trauma and fluid resuscitation.
Capillary refill 2 seconds: A normal capillary refill time suggests that peripheral circulation is stable, which helps in managing hypovolemia and maintaining adequate tissue perfusion.
pH 7.40: A normal pH supports the concept of ventilation support being effective and adequate. A normal pH indicates appropriate respiratory function and acid-base balance.
PaCO2 42 mmHg: A normal PaCO2 suggests that the client’s ventilation is adequate and CO2 is being eliminated appropriately, which is part of ventilation support.
Surgical dressing dry and intact: This observation indicates that there is no significant infection risk at the incision site. Keeping surgical dressings dry and intact helps prevent infection.
Pain 0 on a scale of 0 to 10: The client reports no pain, which indicates effective pain and anxiety control, providing comfort and minimizing stress.
Temperature 98.1°F (36.7°C): A normal body temperature indicates that there is no active infection or fever, supporting the goal of infection prevention.
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