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Exhibits

Select the 4 (four) orders that are priority.

Cefepime 2grams IV every 12 hours

Stat lactate level

Fingerstick glucose every 6 hours

Obtain a set of blood cultures

Discontinue indwelling catheter

Discontinue Furosemide

1000mL Lactated Ringer's at 170mL/hr

Answer and Explanation

Correct Answer : A,B,D,G

A. Cefepime 2grams IV every 12 hours: Cefepime is a broad-spectrum antibiotic, and the patient’s clinical signs, including fever, elevated WBC count, and confusion, suggest a possible infection. Immediate administration of antibiotics is critical to treat any potential infection.

B. Stat lactate level: The elevated lactate level (7.0 mmol/L) is concerning for tissue hypoxia or sepsis. Monitoring lactate levels helps assess the severity of the infection or potential sepsis, and obtaining this level stat is necessary to guide further treatment.

C. Fingerstick glucose every 6 hours: While monitoring blood glucose is important, it is not the highest priority in this acute situation, especially with more pressing concerns like infection and dehydration. However, it will be monitored regularly, as indicated in the provider's orders.

D. Obtain a set of blood cultures: Blood cultures are essential to identify the causative organism if the patient has an infection. With signs of systemic infection and elevated WBC, blood cultures should be obtained to determine the appropriate treatment.

E. Discontinue indwelling catheter: Although removing the catheter is important to reduce the risk of infection (especially with cloudy urine), it is not an immediate priority compared to addressing infection, sepsis, and fluid balance.

F. Discontinue Furosemide: While discontinuing Furosemide may be important due to the patient’s low blood pressure and potential fluid imbalance, it is not the most urgent intervention compared to starting antibiotics, correcting lactate levels, and fluid resuscitation.

G. 1000mL Lactated Ringer's at 170mL/hr: Given the patient’s potential sepsis and dehydration from diuresis, initiating IV fluid resuscitation with Lactated Ringer’s is a priority. This helps restore circulatory volume and supports organ function.

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

Explanation

A. Apply compression stockings: Compression stockings help improve venous return and prevent blood stasis in the lower extremities, which is a major risk factor for deep vein thrombosis (DVT) and pulmonary embolism.

B. Ambulate the client early: Early ambulation is one of the most effective ways to reduce the risk of venous thromboembolism, including pulmonary embolism, by promoting circulation and preventing blood stasis.

C. Administer aspirin and warfarin: While anticoagulants such as warfarin may be used in certain high-risk patients, they are not typically prescribed immediately postoperatively unless indicated by specific risk factors.

D. Maintain the head of the bed at 90 degrees: Keeping the head of the bed at 90 degrees does not directly impact the risk of pulmonary embolism. It is more important to maintain the head of the bed at 30-45 degrees to promote comfort and prevent complications like deep vein thrombosis or respiratory distress.

E. Encourage client to do active leg exercises: Active leg exercises, such as ankle pumps, help stimulate circulation and reduce the risk of blood clots, which can ultimately decrease the risk of pulmonary embolism.

A. Wash hands with soap and water B. Don a clean pair of nonsterile gloves C. Wash hands with alcohol-based hand sanitizer D. Wash hands with a bleach wipe from a nearby container

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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Exhibits Select the 4 (four) orders that are priority.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is working on a surgical unit and is caring for a client who returned from the Post Anesthesia Care Unit (PACU) 90-minutes ago. Which interventions will decrease the client's risk of developing a pulmonary embolism? (Select All that Apply.)

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

Explanation

A nurse is caring for a client with the diagnosis of clostridium difficile. While providing care to the client, the nurse's glove tears. After removing the soiled gloves, what is the priority action by the nurse?

Correct Answer is A

Explanation

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Exhibits Select the 4 (four) orders that are priority.

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Exhibits

Select the 4 (four) orders that are priority.