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Exhibits

Review H and P, laboratory results, flow sheet, and orders.

The nurse notifies the health care provider of the lab values, blood pressure and pulse, and current intake and output.

Which prescriptions does the nurse expect the healthcare provider to write based on the information? Select all that apply.

Turn off the suction on the nasogastric tube

Bolus calcium

Increase the intravenous fluid rate

Add potassium to the intravenous fluids

Administer a diuretic

Flush the central line with 3% sodium chloride

Decrease the percentage of sodium in the intravenous fluids

Answer and Explanation

Correct Answer : A,C,D

A.   Turn off the suction on the nasogastric tube. The client has been experiencing continuous nasogastric (NG) suction, which can lead to fluid and electrolyte imbalances. The client's low blood pressure (86/64 mm Hg), leg cramping, and fatigue suggest volume depletion and possible electrolyte loss. Discontinuing NG suction will help prevent further fluid loss and electrolyte depletion.
B.   Bolus calcium. The client’s calcium levels (9.2 mg/dL and 9.1 mg/dL) are within normal range (8.5–10.2 mg/dL). Since there is no indication of hypocalcemia, a calcium bolus is not necessary.
C.   Increase the intravenous fluid rate. The client’s low blood pressure, tachycardia (96 bpm), and signs of fatigue suggest hypovolemia, likely due to fluid losses from NG suction and inadequate IV fluid replacement. Increasing IV fluid rate can help restore circulatory volume and improve perfusion.
D.   Add potassium to the intravenous fluids. The client’s potassium level has dropped from 3.8 mEq/L to 3.5 mEq/L, which is at the lower limit of normal (3.5–5.0 mEq/L). Prolonged NG suctioning can cause hypokalemia, leading to muscle cramps, weakness, and fatigue. Adding potassium to IV fluids can prevent further decline and correct the deficiency.
E.   Administer a diuretic. The client is already hypovolemic due to NG losses, as evidenced by low blood pressure and tachycardia. A diuretic would further exacerbate volume depletion, making it an inappropriate intervention.
F.   Flush the central line with 3% sodium chloride. The client's sodium levels are normal (139–142 mEq/L), so a hypertonic saline flush (3% NaCl) is not needed. This type of fluid is typically used for severe hyponatremia, which is not present in this case.
G.   Decrease the percentage of sodium in the intravenous fluids. The client is receiving Dextrose 5% in 0.9% sodium chloride, which provides isotonic hydration. Since the sodium level is within normal limits and the client is hypovolemic, reducing sodium concentration in IV fluids is not necessary.

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Naxlex Comprehensive Predictor Exams

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

Explanation

A. FLACC Postoperative Pain Scale: The FLACC (Face, Legs, Activity, Cry, Consolability) Scale is commonly used for infants and young children who cannot verbally report their pain. It assesses behavioral cues such as facial expressions, leg movement, activity level, crying, and ability to be consoled, making it appropriate for this 4-month-old infant.
B. Riley Infant Pain Scale: This scale is specifically designed for infants under 1 year of age. It evaluates facial expression, sleep patterns, movements, crying, and verbal cues to determine the level of discomfort. Since this infant is postoperative and unable to self-report pain, this scale is a useful tool.
C. Poker Chip Tool: This tool is used for older children, typically 4 years and above, who can understand the concept of counting and associating poker chips with pain intensity. It is not appropriate for a 4-month-old infant who lacks the cognitive ability to use symbolic representation.
D. Visual Analog Scale: This scale requires the client to mark pain intensity on a continuous line, making it appropriate only for older children (around 7 years and older) who understand abstract concepts. A 4-month-old infant cannot comprehend or use this scale.
E. Numeric: The numeric pain scale (0–10) is used for older children and adults who can assign a number to their pain. Infants and young children cannot use this scale, making it inappropriate for this client.
F. FACES: The Wong-Baker FACES Pain Rating Scale is designed for children 3 years and older who can recognize and correlate facial expressions with pain levels. A 4-month-old does not have the cognitive ability to use this scale reliably.

A. Influenza. B. Chickenpox. C. Mumps. D. Sore throat.

Correct Answer is D

Explanation

A. Influenza. Influenza is a viral illness that causes respiratory symptoms and fever, but it is not associated with acute rheumatic fever (ARF). ARF is an inflammatory response to a bacterial infection, specifically Group A Streptococcus (GAS).
B. Chickenpox. Chickenpox, caused by the varicella-zoster virus, leads to fever and a vesicular rash but does not trigger rheumatic fever. Rheumatic fever results from an abnormal immune response following a Streptococcus pyogenes infection.
C. Mumps. Mumps is a viral infection affecting the salivary glands, causing swelling and fever, but it is unrelated to the pathophysiology of ARF. The condition primarily spreads through respiratory droplets, and its complications are distinct from rheumatic fever.
D. Sore throat. A recent sore throat, especially if caused by untreated or inadequately treated Group A Streptococcus, is the most significant risk factor for developing acute rheumatic fever. ARF is an autoimmune inflammatory response occurring weeks after streptococcal pharyngitis, potentially leading to carditis, arthritis, and chorea. Prompt diagnosis and treatment of strep throat with antibiotics can prevent ARF.

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse determines the client is in pain. Which pain scales would be appropriate for this client? Select all that apply.

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

Explanation

A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?

Correct Answer is D

Explanation

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