Try Naxlex NCLEX-RN (Free-Trial)

A nurse on a step-down unit is admitting a client.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first

followed by .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Rationale for correct choices:

  • Apply oxygen via nasal cannula: The client’s oxygen saturation levels of 87–88% on room air indicate moderate to severe hypoxemia, requiring immediate correction. Since the client has a history of COPD and is post-MI, improving oxygenation is essential to reduce myocardial workload and prevent further ischemia or respiratory distress.
  • Initiating a consult for cardiac rehabilitation: Once the client's immediate needs are stabilized, early initiation of cardiac rehabilitation is appropriate. This supports physical recovery, promotes lifestyle changes like smoking cessation and exercise, and reduces future cardiac risk.

Rationale for incorrect choices:

  • Administer a second dose of nitroglycerin: The client’s chest pain has resolved following the initial dose, so there is no current indication to give a second dose. Re-administering nitroglycerin unnecessarily can lead to hypotension or reflex tachycardia, especially risky in a post-MI patient.
  • Request a prescription for a PRN anxiolytic: The client has already been prescribed alprazolam 0.5 mg three times daily, and their anxiety has improved. Requesting an additional anxiolytic is unnecessary at this point and does not address the more urgent issue of low oxygen saturation.
  • Requesting a prescription for a WBC count: There are no signs or symptoms of infection such as fever, chills, or elevated WBC to justify this request. The focus should remain on the client’s cardiopulmonary status and rehabilitation rather than diagnostics that are not clinically indicated.
  • Administering a bolus of fluids: There is no clinical indication of fluid volume deficit, hypotension, or dehydration. Administering fluids to a post-MI patient with COPD may lead to fluid overload, pulmonary edema, or increased myocardial strain.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["D","E","F"]

Explanation

Rationale for correct choices:

  • DTR 2+ bilaterally: This is within the normal range and shows recovery from previous central nervous system depression caused by magnesium sulfate toxicity, which earlier caused a drop to 1+.
  • Urine output 40 mL in the last hour: Output is improving from the prior 20 mL/hr, suggesting better renal perfusion and clearance of magnesium. Adequate urine output is critical to prevent accumulation and toxicity.
  • Oxygen saturation 95% on 2 L nasal cannula: This value meets the prescribed goal and reflects stabilized respiratory function after earlier shallow breathing. It indicates successful oxygenation support.

Rationale for incorrect choices:

  • Temperature 38.3° C (101° F): This is an elevated temperature and may indicate systemic infection or inflammation. It does not support an improvement in condition and warrants monitoring.
  • Heart rate 58/min: This is bradycardia and could indicate lingering effects of magnesium toxicity or a vagal response. It does not reflect improvement and needs further assessment.
  • Blood pressure 146/96 mm Hg: Although slightly lower than the earlier reading of 170/112 mm Hg, it is still in the hypertensive range and does not signify resolution of preeclampsia or stabilization.

Correct Answer is ["2"]

Explanation

  • Convert the available strength from milligrams (mg) to micrograms (mcg) to match the desired dose's unit.

Available strength = 0.025 mg/tablet

Since 1 mg = 1000 mcg,

Calculation:

Desired dose = 50 mcg.

Available strength in mcg = 0.025 mg/tablet × 1000 mcg/mg

= 25 mcg/tablet.

Calculate the number of tablets to administer.

Number of tablets = Desired dose (mcg) / Available strength (mcg/tablet)

= 50 mcg / 25 mcg/tablet

= 2 tablets.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register