A nurse is caring for a client who has hypotension, cool and clammy skin, tachycardia, and tachypnea.
In which of the following positions should the nurse place the client?
High-Fowler's.
Side-lying.
Feet elevated.
Reverse Trendelenburg.
The Correct Answer is C
The nurse should place the client in a position with their feet elevated.
This position helps to increase blood flow to the vital organs and can help improve the client’s blood pressure.
Choice A is not the answer because the Reverse Trendelenburg position does not help improve blood flow to vital organs.
Choice B is not the answer because the side-lying position does not help improve blood flow to vital organs.
Choice D is not the answer because High-Fowler’s position does not help improve blood flow to vital organs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
“The client’s capillary refill in the left toe is 6 seconds.” Capillary refill time is the time it takes for blood to return to the capillaries after pressure has been applied to the skin.
A normal capillary refill time is less than 2 seconds.
A capillary refill time of 6 seconds indicates poor blood flow to the left toe and requires immediate intervention by the nurse.
Choice B is not the correct answer because while a pain level of 7 on a scale from 0 to 10 at the operative site is concerning, it does not require immediate intervention by the nurse.
Choice C is not the correct answer because an oral temperature of 38.3° C (100.9° F) is only slightly elevated and does not require immediate intervention by the nurse.
Choice D is not the correct answer because while 100 mL of blood in a closed-suction drain may be concerning, it does not necessarily require immediate intervention by the nurse.
Correct Answer is B
Explanation
“Furosemide.” The nurse should anticipate administering furosemide because the client’s symptoms of bounding peripheral pulses, hypertension, and distended jugular veins may indicate fluid overload.
Furosemide is a diuretic medication that can help reduce fluid overload by increasing urine output.
Choice A is incorrect because diphenhydramine is an antihistamine medication that is not used to treat fluid overload.
Choice C is incorrect because acetaminophen is a pain reliever and fever reducer that is not used to treat fluid overload.
Choice D is incorrect because pantoprazole is a proton pump inhibitor that is used to treat acid reflux and stomach ulcers, not fluid overload.
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