Exhibits

Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?

Give a bolus of 1,000 mL 0.9% sodium chloride

Repeat blood gas in 1 hour

Place the client in a prone position

Perform endotracheal suctioning

Chest x-ray now

Administer inhaled corticosteroid

Answer and Explanation

Correct Answer : B,C,D

A. Giving a bolus of 1,000 mL 0.9% sodium chloride is typically used to treat hypovolemia or electrolyte imbalances, which are not indicated by the patient's current lab values or clinical
situation.
B. Repeating the blood gas in 1 hour is a reasonable order as it would provide information on whether the patient's respiratory status is improving following interventions for ventilator-associated pneumonia.
C. Placing the client in a prone position can improve oxygenation in patients with respiratory distress by redistributing lung perfusion, making it a suitable intervention for this patient with diminished breath sounds and crackles.
D. Performing endotracheal suctioning would help clear secretions, which may be contributing to the patient's diminished breath sounds and crackles, and is consistent with the care for a patient with pneumonia.
E. A chest x-ray now would typically be ordered if there was a suspicion of a new onset condition such as a pneumothorax or pleural effusion, which is not indicated by the patient's current presentation.
F. Administering an inhaled corticosteroid is generally used for long-term management of chronic respiratory conditions and is not typically used for acute management of ventilator-associated pneumonia.

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Correct Answer is C

Explanation

A. Evaluating upper and lower extremities for perfusion, pulse volume, and pitting edema is important in assessing peripheral perfusion, but the priority action in this scenario is to initiate treatment for a suspected myocardial infarction.
B. Placing an indwelling urinary catheter and instituting strict intake and output measurements is not the priority action in this scenario. The client's symptoms and history suggest a cardiac event requiring immediate intervention.
C. Administering four 81 mg aspirin tablets (324 mg total) as soon as possible is the priority action for a client presenting with chest pain suggestive of acute coronary syndrome. Aspirin helps to prevent platelet aggregation and reduce the risk of clot formation.
D. Securing client consent for coronary angiography and percutaneous coronary intervention may be necessary but is not the immediate priority. The client needs immediate treatment to alleviate symptoms and stabilize the condition.

A. Advise the UAP to resume positioning the client on schedule. B. Assume total care of the client to monitor neurologic function. C. Encourage the UAP to provide comfort care measures only. D. Assign a practical nurse to assist the UAP in turning the client.

Correct Answer is A

Explanation

Even though the client has a "Do Not Resuscitate" (DNR) order, routine care such as turning the client to prevent complications (e.g., pressure ulcers) remains important. The nurse should ensure the UAP understands the need to continue positioning the client according to the care plan, as this is a preventive measure for comfort and overall care, not a resuscitative measure.

B. Assume total care of the client to monitor neurologic function: Assuming total care may not be necessary, but providing guidance on comfort care measures is appropriate.
C.

Comfort care measures are important, but preventing complications such as pressure ulcers by turning the client is also part of providing comfort and care. Ceasing turning the client prematurely could lead to additional complications, which is not in the best interest of the patient.

D. Assign a practical nurse to assist the UAP in turning the client: While additional assistance may be helpful, ensuring that comfort care measures are provided is the priority.

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Exhibits Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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Exhibits

Based on the assessment and blood gas results, which 3 orders should the nurse expect from the healthcare provider?