The patient is a 65-year-old male admitted to the medical surgical unit after a total cholecystectomy.
He has a past medical history of hypertension, heart failure, type 1 diabetes mellitus, cholelithiasis, and cholangitis. Which physician orders would the nurse anticipate being prescribed after reporting findings? Select all that apply.
Stat ventilation/perfusion (V/Q) of chest.
Place patient on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
Stat 2 views chest x-ray.
Send sputum for culture & sensitivity stat.
Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.
Start the patient on antibiotic therapy.
Correct Answer : B,C,E,F
B. Place patient on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
Rationale:
Hypoxemia: Patients who have undergone cholecystectomy are at risk for developing hypoxemia due to various factors, including:
Atelectasis: Collapsed lung tissue can impair gas exchange, leading to low oxygen levels in the blood.
Pneumonia: A potential post-operative complication that can cause inflammation and fluid buildup in the lungs, hindering oxygen uptake.
Pain: Post-surgical pain can inhibit deep breathing and coughing, which are essential for maintaining adequate lung function.
Oxygen Therapy: Supplementing oxygen helps to increase oxygen saturation and improve overall tissue oxygenation, reducing the strain on the heart and other organs.
Oxygen Saturation Goal: Maintaining oxygen saturation at or above 95% ensures that the patient's tissues are receiving sufficient oxygen to meet their metabolic needs.
C. Stat 2 views chest x-ray.
Rationale:
Chest X-ray: A valuable diagnostic tool that can visualize the lungs and surrounding structures, aiding in the assessment of: Atelectasis: Appears as areas of increased density on the x-ray, indicating collapsed lung tissue.
Pneumonia: May present as consolidation (solid white areas) or infiltrates (patchy areas of increased density) on the x-ray. Pleural effusion: Fluid accumulation in the pleural space, which can impair lung expansion and gas exchange.
Pneumothorax: Presence of air in the pleural space, which can cause lung collapse and respiratory distress.
Early Detection: Prompt identification of respiratory complications through chest x-ray allows for timely interventions and prevents further deterioration of the patient's condition.
E. Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.
Rationale:
CBC: Assesses for signs of infection or inflammation, including:
Elevated white blood cell count (leukocytosis) Increased neutrophils (neutrophilia)
Anemia (low red blood cell count)
BMP: Evaluates electrolyte and kidney function, which can be affected by infections and post-operative complications.
Blood Cultures: Determines the presence of bacteria in the bloodstream, allowing for identification of the causative organism and guiding appropriate antibiotic therapy.
F. Start the patient on antibiotic therapy.
Rationale:
Infection Risk: The patient's history of cholangitis and recent surgery increase the risk of infection. Prophylactic Antibiotics: Often administered after cholecystectomy to prevent post-operative infections.
Early Intervention: Prompt initiation of antibiotic therapy is crucial in managing infections and preventing serious complications such as sepsis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
It is true that antibiotics are not effective against viruses like influenza. They only work against bacteria.
However, while providing this information to the client is accurate, it does not directly address the client's inquiry about taking oseltamivir, which is an antiviral medication.
It's essential for the nurse to guide the client toward the appropriate healthcare provider who can assess the client's condition and make an informed decision about whether oseltamivir is a suitable treatment option.
Choice B rationale:
While it is true that influenza vaccination is most effective when given before exposure to the virus, it is still a relevant consideration even after symptoms have begun.
Studies have shown that antiviral medications like oseltamivir can potentially reduce the severity and duration of influenza symptoms, even when started within 48 hours of symptom onset.
Therefore, simply advising the client that it's too late for vaccination without exploring other potential treatment options would be incomplete and potentially disadvantageous to the client's care.
Choice C rationale:
This is the most appropriate response because it ensures that the client receives a comprehensive assessment and individualized treatment plan from a qualified healthcare provider.
The provider can evaluate the client's symptoms, medical history, and potential risk factors to determine if oseltamivir is a suitable medication.
Additionally, the provider can discuss other potential treatment options, such as over-the-counter medications for symptom relief, and provide guidance on self-care measures to promote recovery.
Choice D rationale:
While over-the-counter medications can help manage some symptoms of influenza, such as fever, aches, and cough, they do not directly target the virus itself.
Antiviral medications like oseltamivir can potentially shorten the duration of the illness and reduce the risk of complications, especially in individuals at higher risk.
Therefore, relying solely on over-the-counter medications without considering antiviral therapy could potentially delay recovery and increase the likelihood of adverse outcomes.
Correct Answer is A
Explanation
Choice A rationale:
Liquefying secretions is the most crucial action to address the client's immediate respiratory concerns. Thickened mucus obstructs airflow, leading to shortness of breath, productive cough, and difficulty breathing upon exertion. Increasing fluid intake thins mucus, making it easier to expel and improving ventilation. This directly addresses the client's current symptoms and promotes airway clearance.
Hydration and Mucociliary Clearance: Adequate hydration is indispensable for optimal mucociliary clearance, the natural mechanism that removes mucus from the airways. Fluids moisten the respiratory tract, allowing cilia (tiny hair-like structures) to effectively move mucus upwards, where it can be coughed out or swallowed.
Thinning Mucus: Water acts as a natural expectorant, thinning mucus and reducing its viscosity. This makes it easier for the client to cough up the mucus, clearing the airways and reducing the sensation of breathlessness.
Decreasing Mucus Production: Dehydration can trigger the body to produce more mucus as a protective response. By staying hydrated, the client can help prevent excessive mucus production, further easing symptoms.
Supporting Overall Respiratory Health: Proper hydration maintains the health of the respiratory system's tissues and cells, promoting efficient gas exchange and reducing inflammation.
Preventing Dehydration-Related Complications: Dehydration can exacerbate respiratory problems and lead to other complications, such as fatigue, headaches, and impaired immune function. Maintaining adequate fluid intake helps prevent these issues.
Key points to emphasize to the client:
Drink fluids throughout the day, even if not feeling thirsty.
Water is the best choice, but clear broths, juices, and herbal teas can also contribute to fluid intake. Avoid caffeine and alcohol, as they can be dehydrating.
Monitor urine output to ensure adequate hydration (urine should be pale yellow or clear).
Increase fluid intake during periods of increased mucus production, such as during respiratory infections or exercise.
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