A client who has sustained blunt abdominal trauma is admitted to the ICU. Upon assessment the nurse notices the following vital signs: T-99F; HR- 148: RR-38; B/P-60/40. The client is diaphoretic and restless. The following selections are approved by the ICU physician. What would be the PRIORITY nurse's action?

Auscultate bowel sounds, record the findings and obtain a 12-lead ECG

Initiate the standing prescription for v Dopamine at 16 mcg/kg/minute

Place soft restraints on the upper extremities and sedate as necessary

Lower the head the bed obtain a pulse ox and increase the rate of iv fluids

Answer and Explanation

The Correct Answer is D

A. Auscultate bowel sounds, record the findings, and obtain a 12-lead ECG
While auscultating bowel sounds can help assess for bowel injury and an ECG is useful for monitoring cardiac function, these interventions are not the priority. The client is in shock and requires immediate intervention to restore perfusion.

B. Initiate the standing prescription for Dopamine at 16 mcg/kg/minute
Dopamine can be used to support blood pressure in shock, but fluid resuscitation is the first-line intervention in hypovolemic shock. Vasopressors like dopamine are typically added after fluid resuscitation if hypotension persists.

C. Place soft restraints on the upper extremities and sedate as necessary
The client's restlessness is likely due to hypoxia and inadequate perfusion, not agitation. Restraints and sedation would delay critical interventions and could worsen hemodynamic instability.

D. Lower the head of the bed, obtain a pulse ox, and increase the rate of IV fluids
The client is in hypovolemic shock due to suspected internal bleeding. Lowering the head of the bed improves cerebral perfusion, increasing IV fluids restores intravascular volume, and checking pulse oximetry ensures adequate oxygenation. This is the priority action to stabilize the client.

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Correct Answer is C

Explanation

A. Diphenhydramine 50 mg PO
Diphenhydramine (Benadryl) treats mild allergic reactions but is not sufficient for anaphylaxis. The presence of SOB and angioedema suggests airway compromise, requiring epinephrine.

B. Famotidine 40 mg PO
Famotidine (H2 blocker) can help with allergic reactions but is not the priority in an emergency.

C. Epinephrine 1 mg IM
Epinephrine is the first-line treatment for anaphylaxis. It reverses airway swelling, hypotension, and bronchoconstriction. The standard IM dose is 0.3-0.5 mg, not 1 mg, but epinephrine remains the priority drug.

D. A fluid bolus of normal saline
IV fluids help treat hypotension in anaphylaxis, but epinephrine is the priority intervention.

A. Hydrocodone and acetaminophen 5/500 mg PO B. Carbamazepine 200 mg Po C. Methotrexate 5 mg PD D. Linezolid 600 mg PO

Correct Answer is B

Explanation

A. Hydrocodone and acetaminophen 5/500 mg PO
Opioids are generally ineffective for neuropathic pain, and trigeminal neuralgia is best managed with anticonvulsants.

B. Carbamazepine 200 mg PO
Carbamazepine (an anticonvulsant) is the first-line treatment for trigeminal neuralgia. It helps reduce nerve excitability and pain episodes.

C. Methotrexate 5 mg PO
Methotrexate is an immunosuppressant and chemotherapy drug, not used for trigeminal neuralgia.

D. Linezolid 600 mg PO
Linezolid is an antibiotic used for bacterial infections, not neuropathic pain.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with SOB, wheezes, urticaria, itching and angioedema after receiving vancomycin IV. What is the priority nursing intervention after stopping the medication? Administer:

Correct Answer is C

Explanation

The nurse is caring for a client with trigeminal neuralgia. Which medical prescription would the nurse anticipate?

Correct Answer is B

Explanation

The nurse cannot auscultate bowel sounds during the assessment of a client who has had a repair of an abdominal aortic aneurysm four days ago. The client is complaining of severe abdominal pain and the abdomen is distended. What action should the nurse take at this time?

The nurse is caring for a burn victim during the emergent phase. Assessment findings include white charred leathery wounds over 72% Total Body Surface Area (TBSA). Following intubation and mechanical ventilation, what is the priority intervention?

For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed? (Select All that Apply.)

The nurse is caring for a client with 40% full thickness burned total body surface area (TBSA) in the Emergency Department. The nurse is awaiting transfer to a regional burn center within 20 minutes. What is the most appropriate initial wound care management while awaiting transfer?

The nurse is caring for a client who has suffered a gunshot wound to the anterior chest. The client has been intubated and is currently being ventilated with a bag-valve device. What is the priority intervention for this client now?

How should the nurse evaluate the client's motor ability and function?