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:While a voiding diary can be useful for monitoring urinary symptoms, the client’s description of urinary retention symptoms requires immediate assessment for bladder distention or obstruction, not just recording voiding patterns.

B: Obtaining a urine specimen is important if a urinary tract infection is suspected, but the symptoms described are more indicative of urinary retention, possibly due to prostate issues, which requires immediate physical assessment.
C:The client’s symptoms suggest urinary retention, which can be detected by palpating the suprapubic area for bladder distention. This is the most immediate assessment to determine if the client has retained urine in the bladder.

D: Cleansing the glans penis is important for hygiene and may prevent infections, but it does not address the underlying issue of bladder fullness and urinary retention.

A. Urinalysis. B. White blood cell (WBC count. C. Sputum culture and sensitivity. D. Serum potassium. E. Red blood cell (RBC count. F. Blood urea nitrogen (BUN).

Correct Answer is ["B","C"]

Explanation

A. Urinalysis: While urinalysis can provide information about urinary tract infections, it is not directly related to monitoring the effectiveness of antibiotic treatment for a respiratory tract
infection.
B. White blood cell (WBC count: Monitoring WBC count can help assess the body's response to infection. A decrease in WBC count can indicate improvement in the infection.
C. Sputum culture and sensitivity: Monitoring sputum culture and sensitivity helps determine if the antibiotic is targeting the specific pathogen causing the respiratory tract infection and if the chosen antibiotic is effective against it.
D. Serum potassium: Monitoring serum potassium levels is important with certain antibiotics,
but it is not directly related to evaluating the effectiveness of antibiotic treatment for a respiratory tract infection.
E. Red blood cell (RBC count: RBC count is not typically monitored to evaluate the effectiveness of antibiotic treatment for a respiratory tract infection.
F. Blood urea nitrogen (BUN): BUN levels are not directly related to assessing the effectiveness of antibiotic treatment for a respiratory tract infection.

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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

An older adult male client arrives at the clinic reporting that his bladder always feels full. The client also reports a weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating the urine stream. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, what laboratory value(s) should the nurse monitor? Select all that apply.

Correct Answer is ["B","C"]

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?