The nurse continues to care for the client.

Exhibits

Which of the following actions should the nurse take? Select all that apply.

Vaginal culture

Obtain provider prescription for antibiotics

Ibuprofen 600 mg every 6 hr for mild to moderate pain

Obtain provider prescription for phenazopyridine

Urine culture

Answer and Explanation

Correct Answer : B,D,E

A.   The client’s symptoms (burning with urination, pain) and urinalysis findings are indicative of a urinary tract infection (UTI), which is typically caused by bacteria in the urinary tract. There are no clear indications of a vaginal infection (e.g., discharge, odor, or other symptoms specific to vaginal infections), so a vaginal culture is not needed for this clinical scenario.
B.   The client’s symptoms and laboratory results (positive leukocyte esterase, WBC casts, cloudy urine) strongly suggest a UTI, and the elevated WBC count further confirms infection. Antibiotics are the primary treatment for a urinary tract infection. For pregnant clients, it is crucial to select antibiotics that are safe in pregnancy, as untreated UTIs can lead to preterm labor, kidney infections (pyelonephritis), and fetal complications.
C.   Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is generally contraindicated during pregnancy, especially in the third trimester, due to its potential for causing premature closure of the ductus arteriosus, renal complications, and increased bleeding risk. Alternative pain management strategies should be used in pregnancy.
D.   Phenazopyridine is a urinary analgesic that can be used to relieve the pain, burning, and discomfort associated with UTIs. However, it is generally not recommended during pregnancy, especially in the first trimester, and should only be used in pregnancy if prescribed by a healthcare provider. There are potential concerns with the safety of phenazopyridine in pregnancy, and it should not be administered without a provider's approval.
E.   A urine culture is a diagnostic test that can confirm the presence of a urinary tract infection and
identify the specific bacteria responsible for the infection. Given the client’s symptoms and positive findings on urinalysis, a urine culture should be obtained to help guide the choice of appropriate antibiotics. This will help ensure the effective treatment of the infection and prevent complications.

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Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B,C"},"E":{"answers":"A"}}

Explanation

Hypercapnia (elevated PaCO2)

Malignant hyperthermia: Yes. Malignant hyperthermia (MH) is a life-threatening condition triggered by certain anesthetic agents, and it leads to hypermetabolism, muscle rigidity, and hypercapnia (elevated carbon dioxide levels.
Latex allergy: No. Hypercapnia is not associated with latex allergy.
Hypovolemic shock: Yes. In hypovolemic shock, hypercapnia can occur as a compensatory response due to tissue hypoxia and poor perfusion. However, it is less directly characteristic of hypovolemic shock than of malignant hyperthermia.
2. Wheezes
Malignant hyperthermia: No. Wheezing is not a typical feature of malignant hyperthermia. Instead, it is primarily characterized by muscle rigidity, hypercapnia, and tachycardia.
Latex allergy: Yes. A latex allergy can cause respiratory symptoms, including wheezing, shortness of breath, or bronchospasm. This can occur when an allergic reaction triggers an asthma-like response in the airways.
Hypovolemic shock: No. Wheezing is not characteristic of hypovolemic shock. Hypovolemic shock primarily involves signs of decreased blood volume and perfusion, such as tachycardia, hypotension, and altered mental status.
3. Urticaria (hives)

Malignant hyperthermia: No. Urticaria is not a feature of malignant hyperthermia. MH is characterized by hyperthermia, muscle rigidity, and tachycardia, not an allergic skin reaction.
Latex allergy: Yes. Urticaria (hives) is a common sign of a latex allergy. An allergic reaction to latex can lead to skin reactions, including hives, itching, or rash.

Hypovolemic shock: No. Urticaria is not a typical finding in hypovolemic shock. In hypovolemic shock, the primary concern is hypotension, tachycardia, cool, clammy skin, and poor perfusion, not skin reactions like hives.
4. Tachycardia

Malignant hyperthermia: Yes. Tachycardia is a prominent feature of malignant hyperthermia, often occurring alongside hyperthermia (high body temperature) and muscle rigidity. The elevated heart rate is a response to the increased metabolic demand and stress during MH.
Latex allergy: Yes. Tachycardia can be a response to an allergic reaction such as latex allergy. In more severe cases, anaphylaxis due to latex exposure can cause a rapid heart rate as part of the body's response to the allergic reaction.
Hypovolemic shock: Yes. Tachycardia is a compensatory mechanism in hypovolemic shock. As the body tries to compensate for fluid loss or reduced blood volume, the heart rate increases to maintain perfusion.
5. Muscle rigidity
Malignant hyperthermia: Yes. Muscle rigidity is a classic sign of malignant hyperthermia. It occurs as a result of abnormal muscle contraction, leading to increased metabolic activity, hyperthermia, and hypercapnia.
Latex allergy: No. Muscle rigidity is not a typical feature of latex allergy.
Hypovolemic shock: No. Muscle rigidity is not characteristic of hypovolemic shock, which is primarily marked by reduced blood volume, hypotension, and poor perfusion.

A. Ask the client to describe her pain. B. Check the client's pedal pulse on the right leg. C. Observe the position of the suspended weight. D. Remind the client to use the incentive spirometer.

Correct Answer is D

Explanation

A. Assessing pain requires clinical judgment and should be done by the nurse.
B. Checking pedal pulses is a nursing task that requires assessment of circulation and requires nursing expertise.
C. Observing the positioning of the weight is a task that requires an LPN or RN as it involves assessing the traction’s effectiveness.
D. Reminding the client to use the incentive spirometer is a task that can be delegated to an assistive personnel (AP) to help prevent respiratory complications.

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The nurse continues to care for the client. Exhibits Which of the following actions should the nurse take? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a right hip arthroplasty. Exhibits For each assessment finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B,C"},"E":{"answers":"A"}}

Explanation

A nurse is developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

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A nurse is caring for a client who has a spinal cord injury. Exhibits For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.

The nurse continues to care for the client.

Exhibits

Which of the following actions should the nurse take? Select all that apply.