Patient Data
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F"]
Explanation
A. Client education is also important, focusing on asthma management, the importance of carrying a non-expired inhaler, and avoiding known triggers.
B. Oxygen therapy via nasal cannula should be considered due to the patient's oxygen saturation of 88% on room air, aiming to maintain SpO2 above 94%.
C. Requesting a list of current medications is essential for reviewing potential drug interactions and ensuring comprehensive care.
D. Trendelenburg position is not indicated for this condition and could exacerbate breathing difficulties.
E. While the patient's condition should be closely monitored, the current information does not suggest an immediate need for intubation; however, the healthcare provider should be notified if the patient's condition worsens.
F. Administering medications as ordered is crucial to address the immediate respiratory distress.
Correct Answer is D
Explanation
A. Auscultating the abdomen for bowel sound activity is important, but the priority is addressing the dehisced and eviscerated wound.
B. Bringing additional sterile dressing supplies is a good idea, but the priority is addressing the dehisced and eviscerated wound.
C. Obtaining a sample of the drainage for laboratory analysis can wait until the client's immediate needs are addressed.
D. Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.
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