Client Profile:

75-year-old who lives alone is admitted to the hospital because of weakness and confusion.

What order by the health care provider should the nurse question?

Increase 0.9% Normal Saline infusion to 250 ml/hr per protocol.

Administer Furosemide (Lasix) 20mg IV push.

Collect UA for culture and sensitivity.

Collect blood cultures and start Vancomycin 1gm IV.

Answer and Explanation

The Correct Answer is B

A. Increase 0.9% Normal Saline infusion to 250 mL/hr per protocol: The client’s low CVP and PAWP, hypotension, tachycardia, and dry mucous membranes indicate hypovolemia and dehydration, likely due to sepsis with fluid losses. Increasing isotonic fluid infusion helps restore intravascular volume, improve perfusion, and stabilize hemodynamics.

B. Administer Furosemide (Lasix) 20 mg IV push: Furosemide is contraindicated because it promotes diuresis and would worsen the client’s hypovolemia. The client’s low filling pressures and hypotension indicate severe fluid deficit, not overload. Administering Lasix could precipitate hypoperfusion, acute kidney injury, and cardiovascular collapse.

C. Collect UA for culture and sensitivity: Urinary tract infection is a common cause of sepsis in older adults. Obtaining a urine culture helps identify the causative organism and guide antibiotic therapy, making this order appropriate and necessary for diagnostic accuracy.

D. Collect blood cultures and start Vancomycin 1 gm IV: Blood cultures are essential before antibiotic administration to identify systemic infection sources. Starting broad-spectrum antibiotics like vancomycin promptly after collection aligns with sepsis management protocols and supports early infection control.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. 0.9% Sodium Chloride (NS): Normal saline is the only intravenous solution that is compatible with packed red blood cells. It maintains the integrity of the red blood cells and prevents hemolysis or clot formation during the transfusion, ensuring safe administration.

B. 0.45% Sodium Chloride: Hypotonic solutions like 0.45% sodium chloride can cause red blood cells to swell and hemolyze. Using this solution with PRBCs can lead to transfusion reactions and ineffective oxygen delivery.

C. 5% dextrose in water (D5W): Dextrose solutions are not compatible with blood products because they promote red blood cell clumping and hemolysis. Administration of PRBCs with D5W can result in serious transfusion complications.

D. Lactated Ringers Solution: Lactated Ringers contains calcium, which can interact with anticoagulants in stored blood and lead to clot formation in the IV line. It is therefore unsafe for use with PRBC transfusions.

A. Hold the next dose. B. Initiate oxygen therapy C. Instruct the client to drink water. D. Administer PRN acetaminophen.

Correct Answer is D

Explanation

A. Hold the next dose: Holding the next dose of a nitrate is not necessary because headaches are a common and expected side effect. Nitrate therapy should continue as prescribed to maintain its therapeutic effect unless contraindications arise.

B. Initiate oxygen therapy: Headaches from nitrate use are due to vasodilation, not hypoxia. Oxygen therapy is not indicated unless the client shows signs of oxygen desaturation or respiratory compromise, which is not described here.

C. Instruct the client to drink water: Hydration does not prevent or relieve nitrate-induced headaches, which are caused by cerebral vasodilation rather than dehydration. This action would not effectively address the symptom.

D. Administer PRN acetaminophen: Nitrate-induced headaches are common and can be treated safely with analgesics such as acetaminophen. Administering a PRN dose relieves discomfort without interfering with the therapeutic benefits of the nitrate.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Client Profile: 75-year-old who lives alone is admitted to the hospital because of weakness and confusion. What order by the health care provider should the nurse question?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to transfuse a client with a unit of packed red blood cells (PRBC’s). Which intravenous solution is correct for use with the PRBC transfusion?

Correct Answer is A

Explanation

A nurse assesses a client after administering the first dose of a nitrate. The client reports a headache. What action would the nurse take?

Correct Answer is D

Explanation

After receiving change of shift report, which client should the nurse assess first?

After the nurse receives report, which client should the nurse assess first?

Client Profile: 75-year-old who lives alone is admitted to the hospital because of weakness and confusion. What order by the health care provider should the nurse question?

A client has been diagnosed with hyponatremia and is confused. Which intervention does the nurse include in the client’s plan of care to relieve the confusion?

The nurse prepares to administer blood transfusion to a client. Which means of identification does the nurse use to ensure that the blood is administered to the correct client?

A client with chronic obstructive pulmonary disease (COPD) has poor gas exchange. Which action by the nurse would support the client’s ventilation?

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse?

A client with genital herpes has painful blisters on her vulva. After teaching the client self-care measures, which statement indicates the need for further education?

Client Profile:

75-year-old who lives alone is admitted to the hospital because of weakness and confusion.

What order by the health care provider should the nurse question?