Exhibits
Which prescriptions would the nurse question? Select all that apply.
Enalapril 10 mg every morning
Chest x-ray now
Admit to the medical floor
Vital signs every 4 hours
Send blood for a complete blood count, electrolytes
Supplemental oxygen 10 L/min via nasal cannula
Ibuprofen 400 mg every 4 to 6 hours PRN for temperature greater than 100.5° F (38.0° C)
Continuous pulse oximetry
Correct Answer : A,F,G
A. Enalapril can potentially cause hyperkalemia and hypotension, which could be detrimental to a client with pneumonia. The prescription should be questioned due to these risks.
B. A chest X-ray may be necessary to assess the extent of pneumonia; thus, it is appropriate and should not be questioned.
C. Admission to the medical floor is necessary for monitoring the client's condition due to pneumonia, so this prescription is appropriate.
D. Monitoring vital signs every 4 hours is essential for assessing the client's condition, making this prescription appropriate.
E. Sending blood for a complete blood count and electrolytes is important to evaluate the patient's infection status and metabolic balance, so this is appropriate.
F. Changing the supplemental oxygen from a face mask to a nasal cannula may compromise oxygenation and should be questioned.
G. Administering ibuprofen could mask fever and may not be advisable in the presence of pneumonia, so this prescription should be questioned.
H. Continuous pulse oximetry is crucial for monitoring the patient's oxygen saturation, especially given the pneumonia diagnosis, making this prescription appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increasing the intake of oral fluids is crucial as it helps to liquefy secretions, making it easier for the client to cough up thick mucus and improve breathing.
B. While anxiety reduction methods can be helpful, addressing the physical symptoms of respiratory distress is more immediate.
C. Monitoring for medication side effects is important, but it is secondary to ensuring effective airway clearance and improving respiratory function.
D. Avoiding crowded areas is a preventive measure but does not address the current issue of managing mucus production and shortness of breath.
Correct Answer is D
Explanation
A. Determine the client's last dose of corticosteroids: This may be helpful later in understanding the client's MS management, but it is not the immediate priority in an acute neurological situation.
B. Determine neurological baseline prior to the fall: While important for comparison, establishing the client’s current status through assessment takes priority.
C. Administer a PRN IV antiemetic as prescribed: Vomiting may be a sign of increased intracranial pressure (ICP); treating the symptom without assessing for underlying neurological compromise could delay recognition of a critical condition.
D. Complete head-to-toe neurological assessment: This is the priority. The client’s confusion and projectile vomiting may indicate a traumatic brain injury with increased ICP. Immediate neurological assessment is necessary to identify life-threatening changes and guide urgent interventions.
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