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.

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Correct Answer is B

Explanation

Choice A reason: Montgomery straps are used for securing dressings, not relevant to chest tube management.

Choice B reason: A padded clamp is essential for chest tube emergencies, such as accidental disconnection or assessing for air leaks. It allows temporary clamping without damaging the tubing.

Choice C reason: A tracheostomy tray is not routinely required for thoracotomy unless airway compromise is anticipated, which is not indicated here.

Choice D reason: Wire cutters are used for sternal wires post-cardiac surgery, not for chest tube care.

A. Constipation B. Dry mouth C. Irregular pulse D. Visual disturbances

Correct Answer is C

Explanation

Choice A reason: Constipation is a common antipsychotic side effect but not immediately life-threatening. It can be managed with dietary adjustments and laxatives.

Choice B reason: Dry mouth is a frequent and manageable side effect of risperidone. It does not require urgent intervention unless it leads to complications like dental issues.

Choice C reason: An irregular pulse may indicate cardiac arrhythmias or QT prolongation, which are serious adverse effects associated with risperidone. This finding requires immediate evaluation and possible discontinuation of the drug.

Choice D reason: Visual disturbances are less common and typically non-urgent unless they indicate a neurological issue. They should be monitored but are not the priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

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?

Correct Answer is C

Explanation

A nurse is caring for a client who is postpartum and expresses concern about how her preschool-age son will react to having a baby sister. Which of the following strategies should the nurse suggest?

A community health nurse is providing education to a group of older adults about immunizations. Which of the following immunizations should the nurse recommend?

A nurse in a pediatric clinic is assessing a toddler at a well-child checkup. After reviewing the child's current medical record, which of the following interventions should the nurse expect the provider to prescribe?

A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

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

A nurse is providing teaching to a guardian of a child who has ADHD. Which of the following strategies should the nurse suggest to improve the child's ability to concentrate?

A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching?