A nurse is caring for a 38-year-old client who presents to the emergency department (ED) in pain.

Exhibits

For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Intravenous fluid administration

Ice packs to affected area 15 min on/15 min off

Ambulation in hallway with supervision

Hydromorphone intravenously (IV) for pain

Acetaminophen orally (PO) for pain

Oxygen 2 L/min via nasal cannula

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"B"}}

Intravenous fluid administration is anticipated as hydration can help reduce the viscosity of sickled cells, improving circulation and potentially reducing vaso-occlusive events.

Ice packs to the affected area are nonessential and could potentially be contraindicated, as cold can cause vasoconstriction and may exacerbate pain.

Ambulation is nonessential during acute pain episodes and should be encouraged when the patient is comfortable and pain is controlled.

Hydromorphone IV for pain is anticipated because it is a stronger opioid than morphine and may be necessary if the pain is unresponsive to oral morphine sulfate.

Acetaminophen PO for pain is nonessential in this scenario as it is unlikely to provide adequate pain relief for severe vaso-occlusive pain.

Oxygen therapy is nonessential given the client's SpO2 is 95% on room air, indicating adequate oxygen saturation; however, it may be considered if there is evidence of hypoxia or respiratory distress. It is crucial to monitor the client's response to pain management interventions and adjust the treatment plan accordingly.

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Correct Answer is D

Explanation

A. Malignant hypertension poses risks for other conditions but is not the primary risk factor for cardiogenic shock.
B. A stroke does not directly lead to cardiogenic shock, though it may have other significant complications.
C. Acute kidney injury affects renal function but is not the primary risk for cardiogenic shock.
D. A myocardial infarction (MI) can impair the heart's pumping ability, leading to cardiogenic shock. This is due to the damage to heart muscle that can severely impact cardiac output and blood pressure.

A. Time of the burn B. Depth of the burn C. Cause of the burn D. Location of the burn

Correct Answer is B

Explanation

A. While the time of the burn can provide information about the potential progression of injury, it is not the primary factor in determining the severity of the burn.
B. The depth of the burn is crucial for assessing the severity of the injury as it directly impacts the treatment required and the potential for complications. Depth determines whether the burn is superficial, partial-thickness, or full-thickness.
C. The cause of the burn is relevant for understanding the mechanism of injury but does not directly affect the assessment of burn severity.
D. The location of the burn is important for assessing potential complications and functional impairment but is secondary to the depth of the burn when determining overall severity.

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A nurse is caring for a 38-year-old client who presents to the emergency department (ED) in pain. Exhibits For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse overseeing care in the intensive care unit (ICU) reviews the shift report on four clients. The nurse recognizes which client to be at greatest risk for the development of cardiogenic shock?

Correct Answer is D

Explanation

A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?

Correct Answer is B

Explanation

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A nurse is caring for a 38-year-old client who presents to the emergency department (ED) in pain.

Exhibits

For each potential healthcare provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.