Patient Data

Exhibits

What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

Increase IV fluids to 150 mL/hr

Monitor for adverse reaction to antibiotics

Repeat CD4+ T-cell count STAT

Initiate airborne isolation

Administer antiemetic

Answer and Explanation

Correct Answer : A,B,E

A.   This intervention is likely to be ordered due to the patient's fever and elevated heart rate, which may suggest dehydration or the need for increased fluid intake to support hemodynamic stability and mitigate the effects of fever and potential dehydration from fever and nausea.

B.   Given the diagnosis of Pneumocystis pneumonia, the patient will likely be on or start antibiotics specific to this infection, such as trimethoprim-sulfamethoxazole. Monitoring for adverse reactions is crucial, especially in a newly diagnosed HIV- positive patient who might be starting multiple new medications.
C.   While it is important to monitor CD4 counts in HIV-positive patients to guide treatment decisions, repeating the CD4 count immediately might not be prioritized unless there are specific clinical changes that suggest a rapid decline in immune function. Given the recent test results showing a CD4 count of 443 cells/mm^3, immediate retesting might not be clinically justified unless guided by other symptoms or considerations not detailed here.
D.   Pneumocystis pneumonia does not require airborne isolation as it is not typically contagious between people under normal circumstances. Instead, it arises as an opportunistic infection in individuals with weakened immune systems. Hence, this order would not be appropriate unless there were other infections suspected that require such precautions.
E.   The patient reports severe nausea, which not only is distressing but can also prevent the patient from taking oral medications and maintain necessary nutrition. Administering an antiemetic can help manage this symptom effectively.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Eating patterns and dietary intake are crucial in managing chronic pancreatitis as certain foods can exacerbate symptoms. Identifying dietary triggers and making appropriate dietary modifications can help alleviate abdominal pain.

B. The activity level of bowel sounds may provide information about gastrointestinal motility but is not directly related to pain management in chronic pancreatitis.

C. Physical activity can impact overall health but may not directly alleviate abdominal pain associated with chronic pancreatitis.

D. The color and consistency of feces may indicate malabsorption or other gastrointestinal issues but may not directly address the client's pain management needs.

A. Alternate IV and IM analgesic medications. B. Administer opioid and non-opioid medication simultaneously. C. Give maximum dosage when score reaches 10. D. Educate client on signs and symptoms of narcotic dependency.

Correct Answer is B

Explanation

A. Alternating IV and IM analgesic medications may be appropriate for pain management in some situations but is not the best initial intervention for continuous, severe pain in a client with stage IV bone cancer.

B. Administering opioid and non-opioid medication simultaneously is an appropriate intervention for managing severe pain, as it addresses pain from multiple pathways and may provide more effective pain relief.

C. Giving maximum dosage when the pain score reaches 10 is not recommended, as it may lead to overmedication and increased risk of adverse effects. Pain management should be based on the client's reported pain intensity and individualized needs.

D. Educating the client on signs and symptoms of narcotic dependency is important but is not the priority intervention in this situation. Pain management and relief should be the immediate focus for the client's comfort and quality of life.

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Patient Data Exhibits What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

Correct Answer is A

Explanation

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?

Correct Answer is B

Explanation

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?

A client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling experienced worsens at night. Which client teaching should the nurse provide?

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.

A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places It over the wound. Which intervention should the nurse implement next?

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Patient Data

Exhibits

What order(s) should the nurse anticipate being prescribed after an update is reported to the healthcare providers? Select all that apply.