Exhibits
Review H and P, nurse's notes, laboratory results, flow sheet, and orders.
Click to mark whether the assessment finding represents a therapeutic result of the sodium bicarbonate administered, a non-therapeutic side-effect, or an unrelated finding.
Heart rate 77 bpm
400 mL Urine Output
Bicarbonate 22 mEq/L (22 mmol/L)
Blood pressure 113/72 mmHg
pH 7.35
Sodium 152 mEq/L (152 mmol/L)
Capillary refill 2 seconds
The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}
Heart rate 77 bpm: Unrelated finding
400 mL Urine Output: Therapeutic result (indicating improved renal function)
Bicarbonate 22 mEq/L (22 mmol/L): Therapeutic result (indicating correction of acid-base imbalance)
Blood pressure 113/72 mmHg: Unrelated finding (within normal range)
pH 7.35: Therapeutic result (indicating improvement in acid-base balance)
Sodium 152 mEq/L (152 mmol/L): Therapeutic result (indicating improved electrolyte balance)
Capillary refill 2 seconds: Therapeutic result (indicating improved perfusion)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
While administering a stool softener or laxative can be important to prevent constipation associated with opioids, it is not the highest priority action at the time of medication administration. Ensuring the client's safety during ambulation takes precedence.
The nursing action with the highest priority when administering a dose of codeine with acetaminophen to a client is:
B. Instruct the client to request assistance when ambulating to the bathroom.
Explanation: Codeine is an opioid medication that can cause drowsiness, sedation, and impaired coordination. It can also have constipating effects. Therefore, the highest priority is ensuring the client's safety while ambulating to the bathroom to prevent falls or other accidents. Instructing the client to request assistance when ambulating is essential to prevent potential injuries.
C. Tell the client to notify the nurse if the pain is not relieved:
This is an important instruction, but it is not the highest priority when the client is about to ambulate. Safety during ambulation is the immediate concern.
D. Advise the client that the medication should start to work in about 30 minutes:
Providing information about when the medication is expected to take effect is helpful but not the highest priority at this moment. Safety during ambulation is the primary concern before the client receives the medication.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"}}
Explanation
Heart rate 77 bpm: Unrelated finding
400 mL Urine Output: Therapeutic result (indicating improved renal function)
Bicarbonate 22 mEq/L (22 mmol/L): Therapeutic result (indicating correction of acid-base imbalance)
Blood pressure 113/72 mmHg: Unrelated finding (within normal range)
pH 7.35: Therapeutic result (indicating improvement in acid-base balance)
Sodium 152 mEq/L (152 mmol/L): Therapeutic result (indicating improved electrolyte balance)
Capillary refill 2 seconds: Therapeutic result (indicating improved perfusion)
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