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.

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Correct Answer is B

Explanation

A. A toileting schedule is unnecessary for an anuric client as they do not produce urine.
B. Anemia is a common complication of chronic kidney disease due to reduced erythropoietin production, so monitoring for signs of anemia is important.
C. High potassium foods should be avoided as impaired kidney function can lead to hyperkalemia.
D. While perineal skin care is important, it is not as critical as monitoring for anemia in this context.

A. Ask the spouse if the client seems to be depressed. B. Tell the spouse to wait outside so the client can be assessed for depression. C. Explain that depression often occurs after a life-threatening experience. D. Encourage the client to further describe his feelings.

Correct Answer is D

Explanation

A. Asking the spouse about the client's depression can provide insights but might not be as effective as directly addressing the client.
B. While privacy is important, the spouse can often provide additional valuable information.
C. Explaining about post-MI depression is informative but does not directly assess the client's current emotional state.
D. Encouraging the client to describe his feelings allows the nurse to perform a thorough assessment of the client’s mental state and identify any signs of depression or anxiety.

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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 planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

Which is the priority nursing problem for a client with hypoparathyroidism?

Patient Data Exhibits Each row and each column must have at least one, but may have more than one, response option selected. Intervention: Promotes safety/ Does not promote safety

The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

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.