Nokea
For each potential prescription, click to specify whether the prescription is expected or not expected for the care of the client.
- A. Administer IV antibiotics
- B. Prepare client for echocardiography
- C. Initiate low-flow supplemental oxygen
- D. Gather supplies for pericardiocentesis
- E. Place peripherally inserted central catheter (PICC)
- F. Collect a blood specimen for culture and sensitivity
Correct Answer:
Rationale: Expected prescriptions for clients with suspected infective endocarditis (IE) include:
• Administering IV antibiotics to kill the infectious pathogen
• Preparing the client for echocardiography to identify valvular dysfunction, chamber enlargement, and vegetations
• Placing a peripherally inserted central catheter for long-term IV antibiotic therapy
• Collecting a blood specimen for culture and sensitivity to identify the infectious pathogen
Initiating low-flow supplemental oxygen is not expected because the client is not exhibiting signs of respiratory distress.
Pericardiocentesis is performed to remove excess fluid from the pericardial cavity and prevent progression to cardiac
tamponade. Pericardial effusions are not commonly expected with IE. Furthermore, this client is not exhibiting signs of
pericardial effusion (eg, muffled heart sounds, substernal pain). Therefore, gathering supplies for pericardiocentesis is not
expected.
You may also like to solve these questions
Complete the following sentence/sentences by choosing from the list/lists of options.This client is most likely experiencing gastrointestinal bleeding related to ----------
- A. Diverticulosis
- B. Ulcerative colitis
- C. Peptic Ulcer disease
Correct Answer: C
Rationale: The client is most likely experiencing gastrointestinal GI) bleeding related to peptic ulcer disease (PUD).
The clients symptoms are most consistent with upper Gl bleeding. PUD is one of the most common causes of upper GI
bleeding due to erosion and ulceration of the protective layers (ie, mucosa) of the upper Gl tract (eg, esophagus, stomach,
duodenum). Impaired mucosa allows digestive enzymes and stomach acid to break down underlying tissues, leading to GI
bleeding and perforation. The client has multiple risk factors for PUD, including history of Helicobacter pylori infection, chronic
NSAID use, smoking, and daily alcohol consumption.
Select 5 findings that require immediate follow-up.
- A. SpO, 92% via nonrebreather mask
- B. unilateral chest wall expansion observed on
inspiration - C. left-sided tracheal deviation noted;
- D. breath sounds diminished throughout the right lung
field - E. Superficial lacerations to the face
- F. BP 90/58; S1 and S2 heard on auscultation; all pulses palpabl
Correct Answer: A,B,C,D,F
Rationale: The nurse should immediately follow up on the following findings:
• Hypoxemia (eg, SpO, 92% on 100% oxygen [nonrebreather mask]) indicates an abnormality with ventilation and/or perfusion.
• Unilateral chest wall expansion on inspiration indicates one side of the lung is not inflating. This is usually due to lung collapse,
which could be due to an internal airway dysfunction (eg, mucous plug blocking air entry) or external compression (eg, pneumothorax).
• Tracheal deviation (ie, displacement of the trachea to one side) occurs when pressure from one side of the chest is higher than the
other, pushing the mediastinal structures to the side with less pressure. This is usually due to a large hemothorax or pneumothorax.
• Diminished breath sounds indicate the lung is not adequately expanding (eg, atelectasis, pneumothorax).
• Hypotension (eg, BP 90/58 mm Hg) occurs from several mechanisms, including compression of the heart (eg, cardiac tamponade)
and/or great vessels (eg, tension pneumothorax), inadequate ventricular filling between heartbeats (eg, supraventricular tachycardia),
volume depletion, and other conditions
Drag words from the choices below to fill in the blank/blanks.The nurse understands that the client is most at risk for------------and------------
- A. Sepsis
- B. Delirium tremens
- C. Respiratory failure
- D. Deep venous thrombosis
- E. Decreased cardiac output
Correct Answer: E,C
Rationale: The nurse understands that the client is most at risk for respiratory failure and decreased cardiac output.
Decreased cardiac output is the most concerning complication in a client with a tension pneumothorax. The trapped air in a tension
pneumothorax causes increased pressure, compressing the affected lung more until it is completely collapsed and then compressing the
heart and great vessels (vena cava, aorta), ultimately inhibiting venous return.
If the pleural pressure continues to increase, eventually the pleural cavity will crowd the trachea, forcing it to deviate (shift) to the unaffected
side where the unaffected lung can be compressed. Clients are at high risk for respiratory failure due to hypoxemia. Without treatment, the
lungs cannot meet the demands for oxygenation and the client will die.
Select 5 findings that require immediate follow-up.
- A. left-sided headache
- B. Bilateral lens opacity
- C. 7.9-Ib (3.6-kg) weight loss within the past month.
- D. blurred vision and redness in the left eye
- E. severe pain in the left eye
- F. red conjunctiva.
- G. Left eye: pupil 4 mm and nonreactive to light
Correct Answer: A,D,E,F,G
Rationale: This client is experiencing signs of acute angle-closure glaucoma (ACG), a medical emergency characterized by a sudden elevation in
intraocular pressure (IOP). The onset of symptoms is typically sudden; however, acute ACG requires rapid intervention to prevent permane
vision loss. Manifestations of acute ACG include:
• Blurry vision
• Unilateral headache
• Sudden, severe eye pain
• Conjunctival redness
• Middilated pupils (4-6 mm) nonreactive to light
Drag words from the choices below to fill in the blanks.The nurse recognizes that the client likely has hyperemesis gravidarum and should monitor for the following maternal complications:---------,------------------, AND -------------
- A. Fluid and electrolyte imbalances
- B. Insufficient gestational weight gain
- C. Intraamniotic infection (chorioamnionitis)
- D. Thyrotoxicosis
- E. Placental abruption
- F. Nutritional deficiencies
Correct Answer: A,B,F
Rationale: Without appropriate treatment, clients with hyperemesis gravidarum are at risk for multiple complications, including:
• Insufficient gestational weight gain, which may be associated with fetal/newborn complications such as preterm birth and a small-for-
gestational-age infant
• Fluid and electrolyte imbalances (eg, hypokalemia) resulting from excessive vomiting and decreased fluid and nutritional intake, whic
could cause life-threatening complications (eg, cardiac dyshythmias) if not corrected
• Nutritional deficiencies (eg, protein, vitamin) resulting from decreased oral intake, which may lead to rare but serious complications
(eg, Wernicke encephalopathy from thiamine [vitamin B1] deficiency)