Exhibits
Based upon the day 3 lab results, which order should the nurse bring to the provider's attention?
Potassium 10 meq IV mini bag
Warfarin 5mg by mouth
Regular insulin 5 units subcutaneously
Discontinue indwelling catheter
The Correct Answer is B
A. Potassium 10 meq IV mini bag: The potassium level is at the lower end of the normal range (3.5 mEq/L), but it is not critically low. Potassium supplementation may be needed, but it is not as urgent as managing the elevated INR and low platelet count.
B. Warfarin 5mg by mouth: The patient's INR is elevated at 5.0 (normal range: 2.0-3.0), which significantly increases the risk of bleeding, especially with low platelet levels (50,000/mm3, normal range: 150,000-450,000/mm3). Given the critical low platelets and elevated INR, this order should be brought to the provider's attention to reduce the bleeding risk.
C. Regular insulin 5 units subcutaneously: The patient’s blood glucose is elevated at 240 mg/dL, but insulin administration at 5 units is appropriate for the patient's condition and not an immediate concern compared to the bleeding risk from Warfarin.
D. Discontinue indwelling catheter: The catheter is scheduled for discontinuation, but this is not as urgent as addressing the bleeding risk associated with the elevated INR and low platelet count.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Inspect the sacrum for blanching: While inspecting for blanching is important for early detection of pressure injuries, it does not directly prevent them. Prevention involves proactive measures like turning and positioning.
B. Frequent turning and positioning: Regular repositioning helps relieve pressure on vulnerable areas and prevents the formation of pressure injuries, especially in immobile patients.
C. Optimizing nutrition: Proper nutrition, including adequate protein and calorie intake, helps maintain skin integrity and supports wound healing, reducing the risk of pressure injuries.
D. Frequent skin assessments: Regular skin checks help identify early signs of pressure injuries such as erythema, warmth, or localized pain allow for early intervention to prevent worsening.
E. Maintaining the head of the bed at a 45-degree angle: Keeping the head of the bed elevated too high can increase pressure on the sacrum and promote shear forces. A lower angle (30 degrees or less) is often recommended to reduce pressure.
Correct Answer is A
Explanation
A. Wash hands with soap and water: Soap and water are the most effective method for removing Clostridium difficile spores from the hands. Alcohol-based hand sanitizers are ineffective against C. difficile spores, so washing with soap and water is the priority.
B. Don a clean pair of nonsterile gloves: While donning new gloves is important for continuing care, it does not address the need to properly disinfect hands after a contamination event, which should be done immediately.
C. Wash hands with alcohol-based hand sanitizer: Alcohol-based hand sanitizers are not effective against C. difficile spores, so they should not be used in this scenario. Soap and water are required to effectively remove the spores.
D. Wash hands with a bleach wipe from a nearby container: While bleach wipes are effective for disinfecting surfaces, they are not intended for hand hygiene. Soap and water should be used to clean hands in this situation.
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