A client with a history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain.
Vital signs are: temperature 102° F (38.9° C), heart rate 138 beats/minute, blood pressure 80/60 mm Hg. Which intervention should the nurse implement first?

Obtain an analgesic prescription.

Infuse an intravenous fluid bolus.

Administer PRN oral antipyretic.

Cover client with a cooling blanket.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While obtaining an analgesic prescription might help to alleviate the client’s joint pain, it is not the first intervention that should be implemented. The client’s vital signs indicate that they are in a state of shock, which is a medical emergency.

Choice B rationale
Infusing an intravenous fluid bolus is often the first step in treating shock. The client’s low blood pressure and high heart rate suggest that they may be experiencing hypovolemic shock, which can be caused by a severe fluid loss. Administering fluids can help to increase blood volume and improve blood pressure.

Choice C rationale
Administering a PRN oral antipyretic would not address the client’s immediate need. The client’s high temperature is a concern, but the low blood pressure and high heart rate are more immediate concerns.

Choice D rationale

Covering the client with a cooling blanket would address the client’s high temperature, but it would not address the more immediate concerns of low blood pressure and high heart rate.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A rationale
Given the client’s risk factors of poor wound healing, decreased bone density, and increased capillary fragility, the most appropriate outcome statement to include in the plan of care is that the client implements measures to prevent injury. This includes avoiding falls, using caution with sharp objects to prevent cuts, and taking steps to protect the bones.
Choice B rationale
While it is important for the client to understand their disease and ways to control it, this is not the most appropriate outcome statement given the client’s specific risk factors.
Choice C rationale
Improving body image may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.
Choice D rationale
Experiencing a normal fluid balance may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.

A. Avoid administering oxygen at high levels for extended periods. B. Increase the oxygen rate during sleep to compensate for a slower respiratory rate. C. Taking a sedative at bedtime slows the respiratory rate, which decreases oxygen needs. D. Oxygen is less toxic when it is humidified with a hydration source.

Correct Answer is A

Explanation

Choice A rationale
Oxygen therapy is a crucial part of the management for patients with severe pneumonia. However, prolonged administration of high concentrations of oxygen can potentially lead to oxygen toxicity, resulting in damage to the cells of the lungs. This is due to the production of

reactive oxygen species which can damage cell structures. Therefore, it is important to avoid administering oxygen at high levels for extended periods.
Choice B rationale
While it might seem logical to increase the oxygen rate during sleep due to a slower respiratory rate, this is not typically recommended. The body’s oxygen requirements do not significantly change during sleep and increasing the oxygen rate could potentially lead to hyperoxia.
Choice C rationale
Sedatives can indeed slow the respiratory rate, but this does not decrease oxygen needs. In fact, it could potentially lead to respiratory depression and hypoxia, especially in a patient with a respiratory illness like pneumonia.
Choice D rationale
Humidification of oxygen can improve patient comfort, especially with high flow rates, by preventing dryness in the nasal passages. However, it does not make oxygen less toxic.

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Naxlex Comprehensive Predictor Exams

The nurse is developing the plan of care for a client diagnosed with Cushing’s syndrome and identifies that the client’s risk factors include poor wound healing, decreased bone density, and increased capillary fragility. Which outcome statement should the nurse include in the plan of care?

Correct Answer is A

Explanation

A 10-year-old child with pneumonia is receiving oxygen at 5 L/minute via a nasal cannula. When planning care for this child, what principle of oxygen administration should the nurse keep in mind?

Correct Answer is A

Explanation

The nurse notices the presence of clear fluid on the surgical dressing of a patient who has just returned to the unit following lumbar spinal surgery. What immediate action should the nurse take?

An adult patient visits the clinic expressing concern about a lump that appeared on their neck about a week ago. Upon examination, the nurse finds a large, non-tender, hardened left subclavian lymph node without any overlying tissue inflammation. What could these findings indicate?

A patient with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. What schedule should the nurse follow to monitor the patient’s blood pressure after this procedure?

A client is experiencing severe agitation and tremors due to withdrawal from the benzodiazepine alprazolam. What is the best initial nursing action?

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mg/kg/min. Which intervention should the nurse implement while administering this medication?

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What interventions should the nurse include in this client’s plan of care? Select all that apply.

A client with hepatic failure has an electrolyte imbalance, elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours. What intervention should the nurse include in the plan of care?