The nurse is caring for a client.
Which of the following 4 orders or prescriptions should the nurse anticipate? Select the 4 orders or prescriptions that the nurse should anticipate.
Obtain ABGS.
Obtain a complete blood count.
Request respiratory therapy for intubation.
Prepare the client for cardiac catheterization.
Obtain a chest x-ray.
Obtain a brain natriuretic peptide (BNP) test.
Obtain a stat MRI.
Correct Answer : A,B,E,F
Rationale:
A. Arterial blood gases will help evaluate the severity of hypoxemia and possible respiratory alkalosis from tachypnea, both of which are common in pulmonary embolism or acute respiratory distress.
B. A CBC helps evaluate for infection (elevated WBCs) and baseline hemoglobin/hematocrit status, especially important postoperatively and in acute deterioration.
C. Although the client is in respiratory distress, oxygen saturation is still 92% on supplemental oxygen and the client is awake and oriented. Intubation is not the immediate anticipated order; less invasive interventions would be tried first unless the client deteriorates further.
D. The presentation is not primarily cardiac ischemia requiring catheterization. The symptoms are more consistent with pulmonary embolism or acute respiratory compromise rather than acute coronary syndrome.
E. A chest X-ray is commonly obtained first to rule out other causes of dyspnea (e.g., pneumonia, atelectasis, pulmonary edema) and to provide baseline lung assessment, even though it may not definitively diagnose PE.
F. BNP may be elevated if there is right-sided heart strain due to a pulmonary embolism or fluid overload. It helps assess cardiac involvement in acute dyspnea.
G. MRI is not indicated for acute respiratory distress in this scenario. It is not useful for evaluating suspected pulmonary embolism or postoperative respiratory complications and would delay urgent care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Calcium levels are not the primary indicator of hepatic encephalopathy. While liver disease can contribute to various electrolyte imbalances, calcium is not the key laboratory value used to monitor or diagnose hepatic encephalopathy.
B. Potassium may be affected in liver disease due to diuretics or fluid shifts, but it is not the defining or most important marker for hepatic encephalopathy. It is monitored for overall metabolic stability, not specifically for encephalopathy severity.
C. Blood glucose should be monitored in clients with liver disease because the liver plays a role in glucose regulation. However, it is not the primary diagnostic or monitoring marker for hepatic encephalopathy.
D. Elevated serum ammonia levels are strongly associated with hepatic encephalopathy. When the liver is unable to properly convert ammonia (a byproduct of protein metabolism) into urea for excretion, ammonia accumulates in the bloodstream and crosses the blood-brain barrier, leading to neurotoxic effects such as confusion, asterixis, and altered level of consciousness. Monitoring ammonia helps assess severity and response to treatment (e.g., lactulose, rifaximin).
Correct Answer is []
Explanation
Rationale for Correct Choices
• Osteoarthritis: The client presents with chronic, localized joint pain in the right knee and left wrist over 2 years, along with crepitus—this is highly characteristic of osteoarthritis (OA), a degenerative joint disorder. OA typically affects weight-bearing joints and is non-inflammatory in nature. Laboratory findings support this diagnosis because ANA is negative, rheumatoid factor is within normal limits, ESR is not elevated beyond normal limits, and there are no systemic symptoms such as rash or fever.
• Instruct the client to apply topical analgesics: Topical analgesics (e.g., NSAID creams) help reduce localized joint pain and inflammation in osteoarthritis without systemic side effects. This is appropriate for chronic degenerative joint pain management.
• Instruct the client to apply heat and cold: Heat helps relax muscles and improve joint mobility, while cold reduces inflammation and pain after activity. Alternating therapy is a standard non-pharmacologic intervention for osteoarthritis symptom relief.
• ESR: Erythrocyte sedimentation rate is a nonspecific marker of inflammation. Although typically normal in osteoarthritis, monitoring helps differentiate OA from inflammatory conditions if symptoms change.
• Joint deformities: Progressive joint degeneration in osteoarthritis can eventually lead to deformities, reduced mobility, and functional decline. Monitoring helps assess disease progression and effectiveness of symptom management.
Rationale for Incorrect Choices
• Gout: Although uric acid is at the upper limit of normal, gout typically presents with acute, episodic, intensely painful attacks (often in the big toe), which is not described here. This client has chronic, gradual pain without acute flares.
• Systemic lupus erythematosus (SLE): SLE would typically present with multisystem involvement, including rash (especially malar rash), photosensitivity, and positive ANA. This client has negative ANA and no systemic symptoms.
• Rheumatoid arthritis (RA): RA typically involves symmetric joint pain, morning stiffness, elevated inflammatory markers, positive rheumatoid factor, and possible joint deformities affecting multiple joints. This client has localized, non-symmetric joint involvement and normal inflammatory labs.
• Instruct the client to avoid live vaccines: This is appropriate for immunosuppressed clients (e.g., RA on immunosuppressants), which does not apply here.
• Instruct the client to use mild soaps for cleaning skin: This is more relevant to dermatologic or autoimmune skin conditions like SLE.
• Instruct the client to avoid foods high in purines: This is specifically related to gout management, not osteoarthritis.
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