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.
Give ibuprofen 400 mg PO every 6 hours PRN for fever
Give 1,000 mL sodium chloride now
Discontinue the peripheral IV
Insert an indwelling urinary catheter
Apply cardiac telemetry monitoring
Collect blood to test electrolyte levels
Prepare to defibrillate the client
Collect blood for a type and screen
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Client positioning during the procedure should be documented to ensure that the procedure was performed correctly and that the client was appropriately positioned for catheter insertion.
B. The amount of lubricant used is not a standard detail for documenting catheter insertion. Documentation focuses on the procedure's outcomes and specific technical details rather than quantities of materials used.
C. The size of the urinary catheter should be documented as it is a critical detail for future reference and to ensure that the catheter was appropriate for the client’s needs.
D. The appearance of the urine obtained should be documented as it provides important information about the client’s urinary status and can indicate potential issues like infection or hematuria.
E. While the amount of urine obtained might be relevant for assessing urinary retention, it is not a standard part of the initial documentation for catheter insertion unless there was a significant volume change or specific concern.
Correct Answer is B
Explanation
A. Eliminating citrus drinks is not specifically related to preventing dumping syndrome. While citrus drinks might irritate the stomach, the main dietary consideration for dumping syndrome is the timing of fluid intake.
B. Consuming fluids 30 minutes to one hour after meals helps prevent dumping syndrome. Drinking fluids too close to meal times can increase the risk of dumping syndrome by accelerating gastric emptying.
C. Increasing the intake of carbonated fluids after meals is not recommended for preventing dumping syndrome. Carbonated drinks can exacerbate symptoms rather than help prevent them.
D. Avoiding caffeinated beverages can be part of general dietary recommendations, but it is not the primary measure to prevent dumping syndrome. The timing of fluid intake relative to meals is more crucial.
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