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Exhibits

Based on the current focused assessment, what prescriptions should the practical nurse (PN) ask the health care provider to add? Select all that apply.

A.

Give ibuprofen 400 mg PO every 6 hours PRN for fever

B.

Give 1,000 mL sodium chloride now

C.

Discontinue the peripheral IV

D.

Insert an indwelling urinary catheter

E.

Apply cardiac telemetry monitoring

F.

Collect blood to test electrolyte levels

G.

Prepare to defibrillate the client

H.

Collect blood for a type and screen

Answer and Explanation

Correct Answer : A,E,F

A. Give ibuprofen 400 mg PO every 6 hours PRN for fever
The client has a fever of 101.5° F (38.6° C), so administering ibuprofen to manage the fever is appropriate.
B. Give 1,000 mL sodium chloride now
This prescription is already ordered and being administered, so it does not need to be requested again.
C. Discontinue the peripheral IV
The client needs IV access for fluid administration and potential medications, so discontinuing the peripheral IV is not appropriate.
D. Insert an indwelling urinary catheter
There is no indication of urinary retention or need for precise fluid measurement, making this intervention unnecessary at this time.
E. Apply cardiac telemetry monitoring
Given the client's elevated heart rate and respiratory rate, cardiac telemetry monitoring would help in continuously assessing the client's cardiac status.
F. Collect blood to test electrolyte levels
Due to the client's symptoms and history of decreased fluid intake, electrolyte imbalance is a concern, and testing electrolyte levels is necessary.
G. Prepare to defibrillate the client
There is no indication of a cardiac emergency that would require defibrillation.
H. Collect blood for a type and screen
There is no indication of the need for a blood transfusion, making this intervention unnecessary.
 


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Related Questions

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D","dropdown-group-3":"D"}

Explanation

  1. Dark Room Lighting
    Consistent with Elder Mistreatment: A dark, uninviting environment can indicate neglect or lack of proper care. It may reflect poor living conditions or neglect of the client's environment, which can be a sign of mistreatment.
  2. Malnutrition
    Consistent with Elder Mistreatment: The client’s low weight (98 lb) relative to her height (5 ft 4 in) suggests potential malnutrition. Malnutrition can be a sign of neglect, as the client might not be receiving adequate food or nutrition, which is a form of mistreatment.
  3. Pressure Injuries
    Consistent with Elder Mistreatment: Although the pressure injuries have closed, the presence of Stage II pressure ulcers in the past indicates a lack of proper care and attention to the client’s needs. Pressure ulcers are a common sign of neglect in care settings.

Not Consistent with Elder Mistreatment

  • Poor Hygiene
    Not Consistent: The client appears clean and healthy with no issues in skin condition or oral hygiene, so this is not a sign of mistreatment.
  • Bilateral Leg Edema
    Not Consistent: While edema might be a concern in heart failure management, it is not specifically indicative of elder mistreatment.
  • Short Term Memory Loss
    Not Consistent: Short-term memory loss is not necessarily a sign of mistreatment; it could be related to aging or medical conditions.

Correct Answer is C

Explanation

A. Observing for signs of pain or discomfort during the treatment is not a direct method for evaluating ondansetron’s effectiveness. Ondansetron is used to prevent nausea and vomiting, not to manage pain.
B. While assessing vital signs is important for overall monitoring, it does not specifically measure the effectiveness of ondansetron for preventing nausea and vomiting.
C. Monitoring for nausea or vomiting following the treatment is the most direct way to evaluate the effectiveness of ondansetron. The primary goal of ondansetron is to prevent or reduce these symptoms associated with chemotherapy.
D. Evaluating if the client feels calm and relaxed is not a measure of ondansetron’s effectiveness. The focus should be on the medication’s ability to prevent nausea and vomiting rather than the client's emotional state before treatment.

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