A nurse on a mental health unit is caring for a client.

Nurses' Notes

Day 1, 1300:

Client admitted following a suicide attempt. Client's family reports client has not left bedroom in 1 week. Client previously. diagnosed with bipolar disorder.

Client reports feeling excessively tired and light-headed. Allergies: Client's family reports allergy to SSRIS (angioedema) and penicillin (anaphylaxis).

1600:

Client has been sleeping in their room since admission. Flat affect noted.

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

Low-sodium diet

Potassium 40 mEq PO daily

Initiate suicide precautions

Fluoxetine 20 mg PO daily

Answer and Explanation

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

A. Low-sodium diet Contraindicated: A low-sodium diet can decrease lithium elimination, leading to increased lithium levels and risk of toxicity in lithium users. B. Potassium 40 mEq PO daily Anticipated: Potassium supplementation may be needed to prevent hypokalemia, which can occur due to lithium-induced polyuria or diuretic use. C. Initiate suicide precautions Anticipated: Suicide precautions are essential for any client who has attempted or expressed suicidal ideation, especially during the depressive phase of bipolar disorder. D. Fluoxetine 20 mg PO daily Contraindicated: Fluoxetine is an SSRI antidepressant, which can cause angioedema in clients who are allergic to SSRIs. Additionally, fluoxetine can trigger manic episodes or increase suicidal risk in clients with bipolar disorder.

Nursing Test Bank

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Correct Answer is D

Explanation

Choice A reason

Re-evaluate the client for an ET cuff leak is not appropriate. While an ET cuff leak could contribute to respiratory distress, the immediate concern is the high-pressure alarm, which indicates increased resistance to airflow. The nurse should address the alarm first and then assess for other potential causes, including an ET cuff leak.

Choice B reason:

Option B: Assess for disconnected tubing is not appropriate. A disconnected tubing is also a potential cause of the high-pressure alarm. However, before checking for disconnected tubing, the nurse should first deliver manual breaths with a resuscitation bag to provide the client with adequate ventilation.

Choice C reason:

Decrease the ventilator flow rate is not appropriate. Decreasing the ventilator flow rate might not be the appropriate action in this situation, as the high-pressure alarm indicates increased resistance, which might require increased flow to overcome. Additionally, the nurse should not delay taking immediate action by adjusting ventilator settings without knowing the specific cause of the high-pressure alarm.

Choice D reason:

When the high-pressure alarm is beeping, and the client is experiencing respiratory distress, it indicates that there is an increased resistance to airflow within the ventilator circuit or the client's airway. This can be a life-threatening situation, and immediate action is required.

A. "I will not allow anyone to smoke near my baby." B. I will place bumper pads in my baby's crib." C. "My baby's head should be placed on a pillow for sleeping. D. "My baby should sleep in a side-lying position."

Correct Answer is A

Explanation

A. Correct. Avoiding exposure to tobacco smoke is one of the measures to prevent SIDS, as it can affect the respiratory function and arousal of the newborn.

B. Incorrect. Placing bumper pads in the baby's crib is not recommended, as they can pose a suffocation or strangulation hazard for the newborn.

C. Incorrect. Placing the baby's head on a pillow for sleeping is not advised, as it can increase the risk of suffocation or rebreathing of carbon dioxide for the newborn.

D. Incorrect. Placing the baby in a side-lying position for sleeping is not suggested, as it can increase the likelihood of rolling over to a prone position, which is associated with a higher incidence of SIDS.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is providing teaching to the guardians of a newborn about measures to prevent sudden infant death syndrome (SIDS). Which of the following guardian statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

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