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The nurse has reviewed the Provider Prescriptions at 0800.

Exhibits

Complete the following sentence by using the list of options.

The nurse should first

followed by .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Rationale for Correct Choices:

  • Have ABGs drawn: Obtaining ABGs is the priority because this client has pneumonia with worsening respiratory status, oxygen saturation dropping to 90% on room air, and signs of hypoxia. ABGs provide immediate information about oxygenation, ventilation, and acid-base balance, which are critical for respiratory distress and guiding oxygen therapy.
  • Administer antibiotics: Administering antibiotics is the next priority after collecting labs, as timely treatment of pneumonia and potential sepsis is critical. The client shows signs of worsening infection with elevated WBC and vital sign changes, and early antibiotic administration improves outcomes and prevents further deterioration.

Rationale for Incorrect Options:

  • Collect blood for BMP: While a BMP is important to assess electrolyte imbalances and kidney function, it is secondary to evaluating respiratory function and oxygenation in this acutely ill client. BMP can be collected after addressing urgent respiratory needs.
  • Encourage PO fluids: While encouraging oral fluids supports hydration and recovery, it may not be feasible or safe initially if the client is confused, agitated, or has respiratory distress. Prioritizing assessment through lab tests before interventions ensures a targeted approach.
  • Implement fall precautions: While fall precautions are important due to the client’s confusion and restlessness, they are a safety measure rather than an immediate clinical intervention. These should be implemented concurrently but do not take precedence over diagnosing and treating the infection.
  • Discontinue oxygen therapy: Discontinuing oxygen therapy is inappropriate given the client’s oxygen saturation drops to 90% without supplemental oxygen. Maintaining adequate oxygenation is essential, especially in pneumonia, and should not be stopped.


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Related Questions

Correct Answer is D

Explanation

A. Uric acid of 6.5 mg/dL: Although hyperuricemia is a common risk factor for gout, a level of 6.5 mg/dL falls within the reference range and may not always indicate an acute attack. Some patients experience gout flares even with uric acid in the normal range.

B. Erythrocyte sedimentation rate (ESR) of 5 mm/hr: An ESR of 5 mm/hr is within the normal range and does not suggest active inflammation. During an acute gout flare, inflammatory markers like ESR are often elevated due to the intense joint inflammation.

C. Decreased C-Reactive Protein (CRP): A decreased CRP is not expected in acute gout. CRP usually rises as part of the systemic inflammatory response, reflecting the acute inflammatory process occurring in the affected joint.

D. Urate crystals in the synovial fluid: The presence of monosodium urate crystals in joint aspirate is the hallmark diagnostic finding in gout. This confirms the diagnosis during an acute attack, as the crystals precipitate in the joint space, causing pain and inflammation.

Correct Answer is C

Explanation

A. A ram's-horn nail should be cut to give a smooth, rounded edge: Ram’s-horn nails (onychogryphosis) are thick, curved, and difficult to trim safely. Cutting them without specialized training may cause injury or infection, so referral to a podiatrist is recommended.

B. Onychomycosis is quickly eradicated with antifungal creams or powders: Fungal nail infections are persistent and difficult to treat, often requiring long-term systemic antifungal therapy. Topical creams or powders are usually ineffective as sole treatment.

C. Maintaining oral hydration may reduce the incidence of xerosis: Xerosis, or dry skin, is common in older adults due to decreased sebaceous gland activity. Adequate oral hydration helps support skin moisture balance.

D. A licensed practical nurse is qualified to care for the feet of a client with diabetes: Foot care for diabetic clients requires advanced assessment skills. Specialized professionals like registered nurses or podiatrists are typically responsible, not LPNs working independently.

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