Exhibits
What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers?
Select all that apply.
Administer antiemetic
Monitor for adverse reaction to antibiotics
Increase IV fluids to 150 mL/hr
Initiate airborne isolation
Repeat CD4+ T-cell count STAT
Correct Answer : A,B,C
A. The client is noted to have emesis which contributes to total fluid loss predisposing the client to acute kidney injury. Antiemetics are important to reduce emesis.
B. Clients with PCP are typically treated with antibiotics, such as trimethoprim-sulfamethoxazole (TMP-SMX), as first-line therapy. Monitoring for adverse reactions to antibiotics, such as hypersensitivity reactions or renal toxicity, is essential for safe medication administration.
Increasing fluid intake prevents and manages acute kidney injury in the client.
C. Increasing intravenous hydration ensures the lost fluid is replaced to prevent acute renal injury that may occur due to hypoperfusion.
D. Pneumocystis pneumonia is caused by the fungus Pneumocystis jirovecii (formerly known as Pneumocystis carinii), and its transmission occurs through the inhalation of airborne fungal spores. However, it is not typically spread from person to person like airborne viral or bacterial infections.
E. Repeating CD4 count is not necessary as it is unlikely to alter the management of the client at this point. This should be after 2-3 weeks.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Pins or wires are often inserted into the bone to apply traction, and these insertion sites provide a potential route for infection. The nurse should assess the pin sites regularly for signs of infection, such as redness, swelling, warmth, or drainage. Early detection and treatment of pin site infections help prevent the spread of infection and promote healing.
A. Administer pain medication at designated intervals around the clock:
While pain management is important for a client with a fracture, the primary intervention for skeletal traction is not necessarily related to pain medication administration.
B. Assessing pulses proximal to the fracture site is important for monitoring circulation and detecting any signs of impaired perfusion. However, this intervention is more relevant to vascular assessment and may not be directly related to skeletal traction.
C. Skeletal traction is typically maintained continuously to provide consistent traction and promote proper alignment of the fractured bone. Removing traction every shift would disrupt the therapeutic effect and delay healing.
Correct Answer is A
Explanation
A. Remaining upright following meals helps prevent gastric contents from refluxing into the esophagus by promoting gravity-assisted emptying of the stomach and reducing intra- abdominal pressure. This can help alleviate symptoms of GERD such as heartburn and regurgitation.
B. Wearing tight fitting clothes can contribute to increased pressure on the abdomen, which may worsen symptoms of GERD by further compressing the stomach and promoting reflux. While avoiding tight fitting clothes is important for minimizing discomfort, it is not as critical as remaining upright following meals in managing GERD symptoms.
C. Spicy foods can exacerbate symptoms of GERD in some individuals by irritating the esophagus and increasing gastric acid secretion. While minimizing intake of spicy foods is advisable for many people with GERD, it may not be as universally important as the instruction to remain upright following meals.
D. Quitting smoking is important for overall health and can help improve symptoms of GERD. However, while smoking cessation is beneficial, it may not directly address the immediate need to minimize symptoms following meals as the instruction to remain upright does.
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