A 45-year-old male presents to the emergency department after experiencing profuse vomiting and diarrhea for 3 days. His blood pressure is 90/60 mmHg, heart rate is 110 beats per minute, and mucous membranes are dry. Which of the following interventions should the nurse prioritize?

Encourage oral intake of water

Administer potassium-sparing diuretic

Restrict fluid intake

Administer IV bolus of normal saline

Answer and Explanation

The Correct Answer is D

A. Encouraging oral intake may not be effective due to the patient's likely need for more rapid rehydration given his low blood pressure and heart rate.
B. A potassium-sparing diuretic is inappropriate in this situation, as the patient is already experiencing fluid loss and requires rehydration, not diuresis.
C. Restricting fluid intake would be contraindicated as the patient is in a state of dehydration and hypotension.
D. Administering an IV bolus of normal saline is the priority intervention to quickly restore fluid volume and improve blood pressure and hydration status.

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Correct Answer is B

Explanation

A. Fluid overload is not an allergic reaction but rather a complication of transfusion related to the volume of fluid administered, thus diphenhydramine would not be appropriate.
B. Urticaria, or hives, is a common mild allergic reaction that can occur during blood transfusions. Administering diphenhydramine can help prevent or treat this response.
C. Hemolysis is a serious reaction involving the destruction of red blood cells, often due to blood type incompatibility; it is not alleviated by antihistamines.
D. Fever can occur during transfusions but is typically due to non-specific immune reactions and does not respond to diphenhydramine.

A. IV antibiotics B. Urinalysis C. Chest x-ray D. Chest tube placement E. Admit to inpatient F. Airborne precautions G. Draw an STI lab panel H. Complete blood count

Correct Answer is ["A","C","E","H"]

Explanation

The nurse anticipates the following orders from the provider based on the suspected diagnosis:

A. IV antibiotics: To treat the suspected infection.
C. Chest x-ray: To assess the lungs for signs of infection, such as pneumonia.
E. Admit to inpatient: The client's worsening condition and need for aggressive treatment warrant hospitalization.
H. Complete blood count: To assess the client's overall health status and identify any abnormalities, such as anemia or infection.

Rationale:

B. Urinalysis: While a urinalysis can be helpful in assessing for urinary tract infections, it is not a priority in this case.
D. Chest tube placement: This is not indicated unless the client develops a pleural effusion or pneumothorax.
F. Airborne precautions: This is not necessary for the client's current condition.
G. Draw an STI lab panel: While this may be relevant for the client's overall health, it is not a priority at this time, especially given the client's acute presentation.

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A 45-year-old male presents to the emergency department after experiencing profuse vomiting and diarrhea for 3 days. His blood pressure is 90/60 mmHg, heart rate is 110 beats per minute, and mucous membranes are dry. Which of the following interventions should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?

Correct Answer is B

Explanation

A nurse is caring for a client in the clinic. Exhibits The nurse anticipates which of the following orders from the provider based on the suspected diagnosis? (Select all that apply)

Correct Answer is ["A","C","E","H"]

Explanation

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg, and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate which of the following acid-base balances?

A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which of the following manifestations should the nurse include in the explanation of initial symptoms?

A 45-year-old male presents to the emergency department after experiencing profuse vomiting and diarrhea for 3 days. His blood pressure is 90/60 mmHg, heart rate is 110 beats per minute, and mucous membranes are dry. Which of the following interventions should the nurse prioritize?

Which of the following signs are commonly associated with fluid volume deficit (hypovolemia)? (Select All that Apply.)

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