A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg. heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important?

Reorient the patient at frequent intervals.

Monitor the patient's electrocardiogram.

Keep the patient in a quiet and darkened room.

Obtain a health history including prior drug use.

Answer and Explanation

The Correct Answer is B

B. Methamphetamine use can cause significant cardiovascular effects, including tachycardia, hypertension, and arrhythmias. Given the patient's presentation with an irregular heart rate and tachycardia, continuous cardiac monitoring through an ECG is essential to assess for any life-threatening arrhythmias or other cardiac complications.

A. Reorientation is important for patients who are disoriented, but in the case of a patient who has admitted to using methamphetamine and is exhibiting signs of agitation and tachycardia, the priority is to ensure the patient's safety and stabilize their condition.

C. While providing a calm environment is beneficial for patients who are agitated, it is not the most important action in this scenario.

D. Obtaining a comprehensive health history, including prior drug use, is important for understanding the patient's background and potential risk factors. However, in this acute situation where the patient is disoriented, agitated, and exhibiting signs of cardiovascular distress, the priority is to address the immediate medical needs and stabilize the patient's condition.

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Correct Answer is C

Explanation

C. Covering the patient with a warm blanket is an appropriate initial intervention to address the patient's hypothermia and shivering. Heat conservation measures, such as using blankets or warming devices, help raise the patient's body temperature and alleviate shivering.

A. While shivering and a low body temperature (hypothermia) can be common postoperative complications, holding opioid analgesics may not directly address the underlying cause of the shivering or hypothermia.

B. Notifying the anesthesia care provider is a prudent action, especially if the patient's shivering and hypothermia are suspected to be related to intraoperative factors such as inadequate warming or anesthesia-induced temperature dysregulation. However, this is not the immediate action.

D. Acetaminophen is not typically indicated as the initial treatment for hypothermia or shivering. While acetaminophen can help reduce fever and discomfort, rectal suppositories may not provide rapid temperature elevation or relief from shivering.

A. A patient who had a tonsillectomy one week ago B. A patient who had a knee replacement surgery this morning C. A patient who had a hernia repair surgery yesterday D. A patient who had an appendectomy two days ago

Correct Answer is D

Explanation

D. Appendectomy is a common surgical procedure to remove the appendix and is considered a moderate surgical intervention. Early ambulation is generally encouraged for patients after appendectomy to prevent complications such as pneumonia, deep vein thrombosis, and ileus.

B. Knee replacement surgery is a major orthopedic procedure that requires early mobilization and rehabilitation to prevent complications such as blood clots, joint stiffness, and muscle weakness. However, the client needs more time before ambulation is initiated

A. Tonsillectomy is a relatively minor surgical procedure that typically does not significantly impact a patient's mobility or ability to ambulate. The patient who had a tonsillectomy one week ago is likely well-recovered and may not require immediate prioritization for ambulation.

C. Hernia repair surgery is typically considered a moderate surgical procedure. While early mobilization is generally beneficial for patients recovering from hernia repair surgery, it may not be as urgent as for patients undergoing major orthopedic surgeries like knee replacement.

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A disoriented and agitated patient comes to the emergency department and admits using methamphetamine. Vital signs are blood pressure 164/94 mm Hg. heart rate 136 beats/min and irregular, and respirations 32 breaths/min. Which action by the nurse is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has just been transported from the operating room to the postanesthesia care unit (PACU) is shivering and has a temperature of 96.5° F (35.8° C). Which action should the nurse take next?

Correct Answer is C

Explanation

A post-operative patient is scheduled for ambulation. Which of the following patients should be prioritized for ambulation?

Correct Answer is D

Explanation

The health care provider orders a patient-controlled analgesia (PCA) machine to provide pain relief for a patient with acute surgical pain who has never received opioids before. Which nursing actions regarding opioid administration are appropriate at this time? (Select all that apply.)

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A nurse is caring for a client who is in Buck's traction. Which of the following actions should the nurse take? (Select all that apply.)

The nurse interviews a patient scheduled to undergo general anesthesia for a bilateral hernia repair. Which information is most important to communicate to the surgeon and anesthesiologist before surgery?

A nurse is caring for a client who is 1-day postoperative following spinal fusion. Which of the following actions should the nurse take?

An unconscious patient who was transferred from surgery to the postanesthesia care unit (PACU) 15 minutes ago has an oxygen saturation of 89%. Which action should the nurse take first?

A nurse is caring for a client who has a fractured right femur and is in balanced suspension traction. The client is reporting pain from muscle spasms. Which of the following actions should the nurse take first?

A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)