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Patient Data

Exhibits

The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

Administering antipyretic medication as needed

Educating client and family on the importance of fluid restrictions

Collaborating with dietician to prepare low protein diet

Monitoring fluid status

Investigating acid/base complication

Assessing for worsening respiratory status

Performing diagnostic testing to determine cause of fever

Reassessing vital signs

Identifying cardiac arrhythmias

Answer and Explanation

Correct Answer : D,F,I

A.   Administering antipyretic medication as needed is important for managing the client's fever and improving comfort, but not as urgent as monitoring fluid, respiratory status, and cardiac function.
B.   Client and family education on fluid management is important but can be addressed after assessing hydration status.
C.   Protein restriction might be necessary for CKD management in the long term, but not the most pressing need right now.
D.   Given the client's history of chronic kidney disease, monitoring fluid status is crucial to prevent fluid overload and ensure adequate kidney function. Accurate intake and output measurements, along with daily weights, are essential.
E.   The bicarbonate level (18 mEq/L) is slightly low, but further investigation can come after addressing the infection.
F.   The chest X-ray shows bibasilar infiltrates, and the client has a high respiratory rate.

Continuous assessment of respiratory status is important to detect any signs of respiratory distress or infection, which may require immediate intervention.
G.   Performing diagnostic testing to determine cause of fever is necessary for identifying the underlying infection, but secondary to immediate stabilization efforts.
H.   Reassessing vital signs is vital for ongoing assessment, but integrated into the monitoring of fluid status, respiratory status, and cardiac function.

I.   The client has an elevated potassium level and an irregular heart rate, putting him at risk for cardiac arrhythmias. Continuous ECG monitoring and immediate identification of any arrhythmias are critical to prevent cardiac complications.

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Correct Answer is ["22"]

Explanation

To calculate the drip rate for an IV, you can use the formula: (Volume to be infused (mL) x Drop factor (gtt/mL)) / Time (min). For the prescribed 1 unit of PRBC at 350 mL to be infused over 4 hours with a drop factor of 15 gtt/mL, the calculation would be: (350 mL x 15 gtt/mL) / (4 hours x 60 minutes/hour). This simplifies to (5250 gtt) / (240 min), which equals 21.875 gtt/min. When rounded to the nearest whole number, the nurse should regulate the infusion to 22 gtt/min.

A. IV administration of benztropine. B. PO administration of divalproex. C. PO administration of lorazepam. D. IV administration of isotonic crystalloid fluid.

Correct Answer is A

Explanation

A. Benztropine is an anticholinergic medication that is effective in rapidly treating acute dystonic reactions, including laryngeal spasms, which can be life-threatening. It works by counteracting the imbalance of neurotransmitters caused by certain medications.
B. Divalproex is used for mood stabilization and seizure control but is not effective in treating acute dystonic reactions.
C. Lorazepam, while useful for anxiety and agitation, is not the first-line treatment for dystonic reactions and does not address the underlying neurotransmitter imbalance.
D. Isotonic crystalloid fluids are important for hydration but do not treat the cause of the dystonic reaction.

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Patient Data Exhibits The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes 1 unit (350 mL) of packed red blood cells (PRBC) to infuse over 4 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter the numeric value only. Round to the nearest whole number.)

Correct Answer is ["22"]

Explanation

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Correct Answer is A

Explanation

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Patient Data

Exhibits

The healthcare provider has assessed the client and completes initial prescriptions. Which three interventions should the nurse prioritize for this client?