Patient Data.

Exhibits

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

Click to mark whether the assessment finding represents a therapeutic result of the sodium bicarbonate administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.

Capillary refill 2 seconds

Blood pressure 113/72 mm Hg

Bicarbonate 22 mEq/L (22 mmol/L)

Sodium 152 mEq/L (152 mmol/L)

400 mL urine output

Heart rate 77 beats/minute

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}

Choice A: Capillary refill 2 seconds

Reason: Capillary refill time is a quick test to assess peripheral perfusion and hydration status. A normal capillary refill time is less than 2 seconds. Initially, the patient had a capillary refill time of 5 seconds, indicating poor perfusion, likely due to dehydration from vomiting and diarrhea. After the administration of IV fluids and sodium bicarbonate, the capillary refill time improved to 2 seconds, which is within the normal range. This improvement indicates that the treatment was effective in restoring adequate perfusion and hydration, making it a therapeutic result.

Choice B: Blood pressure 113/72 mm Hg

Reason: Normal blood pressure for adults is typically around 120/80 mm Hg. The patient’s initial blood pressure was 100/77 mm Hg, which is on the lower side, likely due to dehydration. After receiving IV fluids and sodium bicarbonate, the blood pressure improved to 113/72 mm Hg, which is closer to the normal range. This indicates that the treatment helped to stabilize the patient’s blood pressure, making it a therapeutic result.

Choice C: Bicarbonate 22 mEq/L (22 mmol/L)

Reason: The normal range for bicarbonate (HCO3) is 21 to 28 mEq/L. The patient’s initial bicarbonate level was 15 mEq/L, indicating metabolic acidosis, likely due to severe vomiting and diarrhea. After the administration of sodium bicarbonate, the bicarbonate level increased to 22 mEq/L, which is within the normal range. This indicates that the sodium bicarbonate effectively corrected the metabolic acidosis, making it a therapeutic result.

Choice D: Sodium 152 mEq/L (152 mmol/L)

Reason: The normal range for sodium is 135 to 145 mEq/L. The patient’s sodium level of 152 mEq/L is above the normal range, indicating hypernatremia. This could be a non-therapeutic side effect of the sodium bicarbonate administration, as sodium bicarbonate can increase sodium levels in the blood. Hypernatremia can lead to symptoms such as confusion, muscle twitching, and seizures, and requires careful monitoring and management.

Choice E: 400 mL urine output

Reason: The patient’s urine output of 400 mL is not directly related to the administration of sodium bicarbonate. Urine output is influenced by various factors, including fluid intake, kidney function, and overall hydration status. In this case, the urine output is more likely related to the patient’s overall fluid balance and hydration status rather than a direct effect of the sodium bicarbonate. Therefore, it is considered an unrelated finding.

Choice F: Heart rate 77 beats/minute

Reason: A normal resting heart rate for adults ranges from 60 to 100 beats per minute. The patient’s initial heart rate was 102 beats per minute, which is elevated, likely due to dehydration and metabolic acidosis. After receiving IV fluids and sodium bicarbonate, the heart rate decreased to 77 beats per minute, which is within the normal range. This indicates that the treatment helped to stabilize the patient’s heart rate, making it a therapeutic result.

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Correct Answer is A

Explanation

Choice A reason:

Instructing the client to obtain a prescription for oral terbinafine is the most appropriate action. Oral terbinafine is an antifungal medication that is effective in treating fungal infections of the toenails. It works by inhibiting the growth of fungi, leading to the resolution of the infection. Topical treatments are often insufficient for toenail fungal infections because they do not penetrate the nail bed effectively.

Choice B reason:

Advising the client to obtain a prescription-strength formulation of the ointment is not the best approach. While prescription-strength topical antifungals can be more effective than OTC options, they still may not penetrate the nail bed adequately to treat the infection. Oral antifungals are generally more effective for toenail infections.

Choice C reason:

Suggesting that the client use the ointment twice a day to be more effective is not recommended. Increasing the frequency of application of an ineffective treatment is unlikely to yield better results. The client needs a more effective treatment option, such as an oral antifungal.

Choice D reason:

Reassuring the client that treatment of fungus-infected toenails often takes several months is true but does not address the issue of using an ineffective treatment. While it is important to set realistic expectations about the duration of treatment, the client needs to be directed towards a more effective treatment option.

A. Many of the herbal preparations are helpful primarily because of their placebo effect. B. Topical echinacea is usually used to soothe burns and can cause damage to the skin. C. Echinacea seems to be useful in the treatment of some infections, such as canker sores. D. This product is essentially harmless but also is not very beneficial in treating skin infections.

Correct Answer is C

Explanation

Choice A reason:

While some herbal preparations may have a placebo effect, echinacea has been shown to have active properties that can aid in the treatment of infections. Echinacea contains compounds that boost the immune system and have anti-inflammatory effects, which can help in the healing process of canker sores.

Choice B reason:

Topical echinacea is not typically used to soothe burns, and there is no evidence to suggest it causes damage to the skin. In fact, echinacea is often used in topical preparations to treat skin conditions due to its anti-inflammatory and antimicrobial properties.

Choice C reason:

Echinacea has been found to be useful in treating some infections, including canker sores. Its immune-boosting and wound-healing properties can help reduce the duration and severity of canker sores. This makes it a beneficial herbal remedy for such conditions.

Choice D reason:

While echinacea is generally considered safe and harmless, it is not accurate to say it is not beneficial in treating skin infections. Echinacea has been used traditionally to treat various skin conditions and infections due to its antimicrobial and anti-inflammatory effects.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a fungal infection of the toenail reports to the nurse that the client has been applying an over-the-counter (OTC) triple antibiotic ointment to the infection daily for two weeks without any improvement. Which action should the nurse take?

Correct Answer is A

Explanation

The home health nurse observes that a female client is using a topical preparation that contains echinacea to treat a canker sore. Her husband expresses concern regarding the effectiveness and safety of using herbs. How should the nurse respond?

Correct Answer is C

Explanation

A client with peptic ulcer disease receives a new prescription for cimetidine. Which statement provided by the client requires additional instruction by the nurse?

A client is receiving orlistat as part of a weight management program. Which ongoing assessment should be included in the plan of care to determine the effectiveness of the medication?

The nurse is teaching a client how to use an inhaler device. Which client statement indicates to the nurse that the client understands the instructions?

Which action should the nurse implement to assess the effectiveness of amlodipine?

The healthcare provider prescribes magnesium sulfate 300 mg/hour IV. The IV bag contains magnesium sulfate 4 grams in dextrose 5% in water (D5W) 500 mL. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

The nurse is caring for a client receiving a prescription for sucralfate to treat a peptic ulcer. Which instruction should the nurse provide during discharge education?

The nurse is teaching a client who has been diagnosed with human immunodeficiency virus (HIV) about the antiretroviral medication regimen. Which statement provided by the client requires additional instruction by the nurse?