Question

A patient's data shows the following: Oxygen saturation is 94% on room air, pain is 4 on a scale of 0 to 10, temperature is 99.6°F (37.6°C) orally, and heart rate is 95 beats/minute. Which physician orders would the nurse anticipate being prescribed after reporting these findings? Select all that apply.

Answer 1

Correct Answers:

Place client on oxygen 2 to 4 liters and maintain oxygen saturation at or above 95%.
Stat 2 views chest x-ray.
Stat Complete blood count (CBC), basic metabolic panel (BMP), and blood cultures.

Rationale :

🫁The oxygen saturation of 94% is slightly below the normal range, so supplemental oxygen helps restore and maintain adequate tissue oxygenation.

🩻A chest x-ray is a useful diagnostic test to detect early pulmonary pathology such as infection or infiltrates that could explain the patient’s low oxygen saturation and elevated heart rate.

🧪A CBC, BMP, and blood cultures are necessary to evaluate for infection, inflammation, or electrolyte imbalance, particularly when low-grade fever and tachycardia are present.

🚫A V/Q scan and sputum culture are not immediately warranted, as there are no strong clinical indicators of pulmonary embolism or active respiratory infection.

📌Core Message

Low oxygen saturation, mild fever, and elevated heart rate justify initiating oxygen therapy, obtaining a chest x-ray, and ordering diagnostic blood work to guide further care.

Answer 2

Correct Answers:

Describe the use of an elimination diet to find trigger foods.

Rationale :

🥗Clients with Crohn’s disease benefit from an individualized dietary approach, as triggers vary widely between individuals.

📉An elimination diet systematically removes and reintroduces foods to help identify specific items that exacerbate symptoms.

⚠️Avoiding all gluten or limiting essential nutrients like calcium and iron is not broadly recommended without clinical justification.

💧Fluid restriction is contraindicated in Crohn’s disease, especially during flare-ups when hydration needs are often increased.

📌Core Message

Crohn’s disease requires personalized nutrition management, and an elimination diet is a safe and effective method to identify trigger foods without causing nutrient deficiencies.

Answer 3

Correct Answers:

Risk for aspiration related to difficulty swallowing.

Rationale :

🚨Dysphagia increases the risk of aspiration, which can lead to life-threatening complications like pneumonia or airway obstruction.

🗣️Although the client has severe pain and anxiety, airway protection is always the top nursing priority.

🥣Aspiration risk can be mitigated with diet modifications, positioning, and close monitoring during meals.

📋Other problems like nutrition and anxiety should be addressed, but only after airway safety is ensured.

📌Core Message

For clients with esophageal cancer and dysphagia, aspiration risk is the priority due to the potential for airway compromise and respiratory complications.

Answer 4

Correct Answers:

Check serum creatinine.

Rationale :

🩸Vancomycin is nephrotoxic, so assessing renal function through serum creatinine is critical before administration.

⚠️Impaired kidney function can result in drug accumulation and toxicity, especially with IV antibiotics like vancomycin.

📊Bowel sounds and temperature offer general clinical data but do not impact immediate dosing decisions for nephrotoxic drugs.

🧪Checking creatinine ensures safe medication administration and supports appropriate dosing adjustments if renal impairment is detected.

📌Core Message

Before starting vancomycin, renal function must be assessed via serum creatinine due to the drug’s nephrotoxic potential.

Answer 5

Correct Answers:

Pneumonia

Rationale :

🦠The patient is already diagnosed with pneumonia, a lung infection that matches the described clinical picture.

📋The history of hypertension and previous surgeries does not alter the current infectious diagnosis.

💊No evidence points to dysrhythmia, anemia, or toxicity, making them less relevant to this case.

🫁Symptoms like cough, fever, and elevated respiratory rate would confirm pneumonia as the active condition needing treatment.

📌Core Message

The client’s current diagnosis, symptoms, and clinical context confirm that pneumonia is the primary concern.

Answer 6

Correct Answers:

Pneumonia

Rationale :

🫁The rapid appearance of bilateral pulmonary infiltrates, particularly in the lower lobes, is characteristic of pneumonia.

📆The short time between a clear Day 1 and infiltrate-laden Day 2 supports an acute infectious process rather than chronic disease.

🚫Tuberculosis usually progresses slowly and affects upper lobes, while bronchitis rarely causes infiltrates.

🧬Pulmonary embolism would likely present with sudden symptoms like dyspnea and chest pain, not evolving infiltrates.

📌Core Message

New lower lobe infiltrates appearing within 24 hours strongly suggest pneumonia, a fast-acting lung infection.

Answer 7

Correct Answers:

Advise the patient that healing typically takes several weeks to occur.

Rationale :

📅Proton pump inhibitors like lansoprazole require several weeks to fully heal erosive esophagitis.

👂Patient education is key to set realistic expectations and encourage adherence to therapy.

⚕️Calling the provider or adjusting dosage after just one week is premature unless symptoms worsen.

🔊Auscultating bowel sounds or abdominal girth has no relevance to esophageal healing.

📌Core Message

Lansoprazole requires weeks to resolve symptoms of erosive esophagitis, so continued use with education is essential.

Answer 8

Correct Answers:

Diabetes Mellitus

Rationale :

🧪A hemoglobin A1C of 8.29% is well above the diagnostic threshold for diabetes, which is ≥6.5%.

📈An increase from 7.59% to 8.29% in three months indicates worsening glycemic control.

🩸This lab result reflects chronic hyperglycemia, not a one-time fluctuation or acute hypoglycemic event.

⚠️Prediabetes would be considered with an A1C of 5.7% to 6.4%, so this level confirms full diabetes.

📌Core Message

An HbA1C > 6.5% confirms diabetes mellitus, with a rising trend indicating poor long-term glycemic control.

Answer 9

Correct Answers:

Corneal abrasion

Rationale :

⚠️Ketorolac is contraindicated in corneal abrasions because it can delay healing and increase infection risk.

💉It works by reducing prostaglandin synthesis, which may interfere with natural tissue repair mechanisms.

👁️Other eye conditions like chemical burns or foreign bodies need separate, more urgent interventions before NSAID use.

🔍Reviewing for corneal damage ensures safe ophthalmic use of NSAIDs like ketorolac.

📌Core Message

Corneal abrasions are a contraindication for ketorolac eye drops due to delayed healing and infection risk.

Answer 10

Correct Answers:

Culture for sensitive organisms.

Rationale :

🧫Purulent drainage suggests infection, so wound cultures help identify the causative organism and guide antibiotic therapy.

🧪A C-reactive protein (CRP) is non-specific and supports inflammation diagnosis but does not identify the pathogen.

💉Blood glucose and pH levels may be altered in infection but are not directly related to wound management decisions.

✍️Obtaining a wound culture first ensures that targeted therapy can begin promptly once the results return.

📌Core Message

When purulent drainage is noted, a wound culture is essential to identify the specific pathogen and determine sensitivity to treatment.

2 :
A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

3 :
The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

4 :
The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

6 :
Patient Data shows that on Day 1, there were no active processes. On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side. What is the likely diagnosis?

7 :
A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

8 :
The patient's Hemoglobin A1C today is 8.29% and was 7.59% three months ago. The reference range is 4 to 5.99%. What is the likely diagnosis?

9 :
A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?

10 :
While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

2 : A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

3 : The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

4 : The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

6 : Patient Data shows that on Day 1, there were no active processes. On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side. What is the likely diagnosis?

7 : A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

8 : The patient's Hemoglobin A1C today is 8.29% and was 7.59% three months ago. The reference range is 4 to 5.99%. What is the likely diagnosis?

9 : A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?

10 : While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

2 :
A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

3 :
The nurse is caring for a client who has been admitted with a diagnosis of esophageal cancer. The client reports a pain level of 8 on a 0 to 10 pain scale, dysphagia, anorexia, anxiety, and a hoarse voice. Which nursing problem is the priority for this client?

4 :
The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

6 :
Patient Data shows that on Day 1, there were no active processes. On Day 2, there were small bilateral lower lobes pulmonary infiltrates with the right lower lobe showing increased involvement compared to the left side. What is the likely diagnosis?

7 :
A patient who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

8 :
The patient's Hemoglobin A1C today is 8.29% and was 7.59% three months ago. The reference range is 4 to 5.99%. What is the likely diagnosis?

9 :
A client receives a prescription for ophthalmic ketorolac. Prior to administering the medication, the nurse should review the medical record for which condition?

10 :
While changing a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?