Try Naxlex NCLEX-RN (Free-Trial)

A nurse in the emergency department is assisting in the care of a client.

Click to highlight the findings that require immediate follow-up. To deselect a finding click on the finding again.

Nurses Notes

1630:

Called to client's room by emergency call bell. Client is alert and oriented to person, place, and time. Client is short of breath, intercostal retractions visible. Wheezing auscultated throughout lung fields, Diffuse, raised rash present on trunk. Abdomen soft, nontender

Vital Signs

1630:

Temperature 38.3°C (101°F)

Heart rate 110/min

Respiratory rate 30/min

Blood pressure 90/55 mmHg

Oxygen saturation 91% on room air

Client is short of breath

intercostal retractions visible

Wheezing auscultated throughout lung fields

Diffuse, raised rash present on trunk

Respiratory rate 30/min

Blood pressure 90/55 mmHg

Oxygen saturation 91% on room air

Temperature 38.3°C (101°F)

Client is alert and oriented to person, place, and time.

Heart rate 110/min

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G"]

Shortness of breath. The client is experiencing respiratory distress, which could indicate a severe allergic reaction (anaphylaxis). Immediate intervention is needed to prevent airway compromise and respiratory failure.
Intercostal retractions. Retractions occur when breathing is labored, suggesting airway obstruction or bronchoconstriction. This is a sign of worsening respiratory distress, requiring urgent medical attention.
Wheezing auscultated throughout lung fields. Wheezing suggests bronchospasm, which is common in anaphylaxis and asthma attacks. The presence of diffuse wheezing indicates that the airways are narrowing, making breathing more difficult.
Diffuse, raised rash present on trunk. A new-onset rash following antibiotic administration raises suspicion for anaphylaxis or a severe allergic reaction. Immediate treatment with antihistamines and corticosteroids may be required.
Respiratory rate 30/min. The increased respiratory rate indicates that the client is compensating for airway constriction and hypoxia. This is an early warning sign of impending respiratory failure if not treated promptly.
Blood pressure 90/55 mmHg. The drop in blood pressure suggests anaphylactic shock, where vasodilation and fluid leakage from capillaries lead to hypotension. Immediate administration of epinephrine is necessary to prevent cardiovascular collapse.
Oxygen saturation 91% on room air. A decrease in oxygen saturation indicates impaired gas exchange, likely due to airway swelling and bronchospasm. Supplemental oxygen therapy should be provided to prevent further desaturation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Restart the infusion in the other extremity. While the IV infusion will need to be restarted in a new site, the priority after discontinuing the infusion is to manage the complications of IV infiltration. Restarting the infusion should be done after addressing the swelling and discomfort in the affected limb.

B. Elevate the extremity. Elevating the extremity reduces swelling and promotes fluid reabsorption following an IV infiltration. This helps minimize pain, tissue damage, and further complications, such as compartment syndrome. It is the next priority action after stopping the infusion.

C. Remove the catheter. The catheter should already be removed when the infusion is discontinued due to suspected infiltration. Keeping it in place could worsen tissue swelling and damage. If the catheter has not been removed yet, doing so is essential, but managing swelling and discomfort remains the priority after removal.

D. Apply warm, moist compresses to the site. Warm compresses are typically used for extravasation of non-vesicant solutions to promote circulation and absorption. However, in cases of severe infiltration or swelling, cold compresses may be used initially to reduce inflammation before applying warmth. The priority action is elevation, followed by applying appropriate compresses based on facility protocol.

A. "Instruct the client's visitors not to operate the PCA pump.” B. "Check the client's pain level every 8 hours." C. "Diarrhea is an adverse effect of morphine PCA.” D. "Using morphine PCA increases the client's risk of toxicity."

Correct Answer is A

Explanation

A. "Instruct the client's visitors not to operate the PCA pump.” Only the client should press the PCA button to self-administer medication. Allowing visitors or family members to press the button ("PCA by proxy") increases the risk of over-sedation, respiratory depression, and opioid toxicity. The nurse should reinforce to visitors that only the client should control medication delivery based on their own pain level.

B. "Check the client's pain level every 8 hours." Pain assessment should be performed more frequently than every 8 hours when a client is receiving morphine PCA. Pain, sedation level, and respiratory status should be monitored every 1–2 hours initially and then at regular intervals as determined by hospital protocol to ensure effective pain management and prevent complications such as respiratory depression.

C. "Diarrhea is an adverse effect of morphine PCA." Morphine is an opioid analgesic that commonly causes constipation, not diarrhea. Opioids slow gastric motility, which can lead to delayed bowel movements, bloating, and discomfort. Clients on long-term opioid therapy often require stool softeners or laxatives to prevent opioid-induced constipation.

D. "Using morphine PCA increases the client's risk of toxicity." PCA pumps are designed with preset dose limits and lockout intervals to prevent overdose. While there is a risk of opioid toxicity if the system is misused (e.g., PCA by proxy or improper settings), PCA is actually safer than traditional opioid administration methods because it allows for precise dosing and patient-controlled pain management. Proper monitoring helps prevent complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving a continuous IV infusion and reports pain at the IV insertion site. The nurse observes the arm is swollen and cool to touch. After discontinuing the infusion, which of the following actions should the nurse take next?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about monitoring morphine patient-controlled analgesia (PCA). Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse is collecting a medication history from the parent of a preschooler who comes to the clinic for routine immunizations. For which of the following findings should the nurse withhold the varicella immunization?

A nurse is reviewing the medication record of a client who has hypertension. Which of the following medications should the nurse administer to lower the client's blood pressure?

A nurse is collecting data from a client following the administration of a new medication. Which of the following findings should the nurse identify as a manifestation of an allergic reaction?

A nurse in an outpatient clinic is caring for a client. Select the 6 statements the nurse should include when reinforcing teaching to the client about the newly prescribed medication

A nurse is preparing to administer medications to a client through an enteral feeding tube. Which of the following interventions is appropriate?

A nurse is checking the forearm of a client who received a tuberculin skin test 48 hr ago. Which of the following findings at the injection site should indicate to the nurse a positive result?

A nurse is caring for a client who has Graves' disease and is to start therapy with propylthiouracil. The nurse should expect which of the following outcomes?

A nurse is collecting data from a client who has gout and is taking allopurinol. Which of the following adverse effects should the nurse identify as the priority to report to the provider?