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 D
Explanation
A. Eating a bland diet and avoiding spicy foods are not specific recommendations for diverticulosis management. They may be applicable for other gastrointestinal conditions.
B. Having small frequent meals and sitting up after meals are general dietary recommendations for digestive health but are not specific to diverticulosis management.
C. Eating a soft diet with increased intake of milk and milk products may not be suitable for diverticulosis management, especially if lactose intolerance is present. Additionally, a soft diet may lack sufficient fiber.
D. Eating a high-fiber diet and increasing fluid intake are key recommendations for managing diverticulosis. High-fiber foods help promote regular bowel movements and prevent constipation, which can exacerbate diverticulosis.
Correct Answer is D
Explanation
A. Sipping fluids with each meal may help prevent dehydration and promote hydration but is not the most important dietary instruction post-gastric bypass surgery.
B. Chewing slowly and thoroughly is important for digestion but is not specific to post-gastric bypass dietary needs.
C. Reducing intake of fatty foods is important for overall health but is not the most critical dietary instruction post-gastric bypass surgery.
D. Eating small frequent meals is crucial after gastric bypass surgery to prevent complications such as dumping syndrome, promote adequate nutrient absorption, and manage portion sizes effectively.
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