A nurse is assessing a client who is experiencing profuse vomiting. Upon admission, the client's vital signs were within the expected reference range, but now the client's blood pressure is 86/58 mm Hg, his pulse is 114/min and weak, and his respiratory rate is 27/min. The client appears restless and anxious and states that he thinks he is dying. Which of the following actions should the nurse take first?

Initiate oxygen therapy.

Increase the IV infusion rate.

Elevate the client's feet.

Administer a vasoconstrictor.

Answer and Explanation

The Correct Answer is B

Choice A reason: Oxygen therapy may be helpful if hypoxia is present, but the client’s symptoms suggest hypovolemia from fluid loss due to vomiting. Oxygen does not address the underlying cause.

Choice B reason: Increasing the IV infusion rate is the priority intervention to restore circulating volume and improve perfusion. The client’s hypotension, tachycardia, and restlessness are signs of hypovolemic shock.

Choice C reason: Elevating the feet can help improve venous return, but it is a supportive measure. It does not replace the need for fluid resuscitation.

Choice D reason: Vasoconstrictors are not first-line treatment for hypovolemia. They may worsen tissue perfusion if volume is not restored first.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Teaching about medical equipment requires nursing knowledge and assessment. This task must be performed by a licensed nurse.

Choice B reason: Recording intake is a routine, non-invasive task that can be delegated to assistive personnel.

Choice C reason: Transferring a client is within the scope of assistive personnel, provided the client is stable and proper technique is used.

Choice D reason: Obtaining vital signs is a standard delegated task for assistive personnel, assuming competency and supervision.

Choice E reason: Inserting an NG tube is an invasive procedure requiring clinical judgment and sterile technique. It must be performed by a licensed nurse.

A. "This test will tell me if my baby has a genetic problem." B. "During this test, I must not eat or drink anything." C. "I will get oxytocin during this test." D. "During this test, I will push a button if my baby moves."

Correct Answer is D

Explanation

Choice A reason: Nonstress testing evaluates fetal well-being by monitoring heart rate patterns in response to movement. It does not assess genetic abnormalities.

Choice B reason: Clients are encouraged to eat before the test to stimulate fetal movement. Fasting is not required.

Choice C reason: Oxytocin is used in contraction stress testing, not nonstress testing. The two tests assess different aspects of fetal health.

Choice D reason: During a nonstress test, the client pushes a button when fetal movement is felt. This helps correlate movement with heart rate accelerations.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is teaching a client who is pregnant about nonstress testing. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following adverse effects of the medication is the priority finding for the nurse to report to the provider?

A nurse is assessing a client who has a sliding hiatal hernia. Which of the following findings should the nurse expect?

A nurse is assessing a client who is taking losartan. Which of the following findings should the nurse identify as an adverse effect of this medication?

A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?

A nurse is caring for a client who is 12 hours postoperative following a below-the-knee amputation. Which of the following interventions should the nurse implement?

A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?

A nurse is planning care for an older adult client who has dementia and a nutritional deficit. Which of the following actions should the nurse plan to take?

A nurse is assessing a client who is receiving enteral feedings via an NG tube. The client has developed hyperosmolar dehydration. Which of the following actions should the nurse take when administering the client's feedings?