A nurse receives report on four clients at the beginning of the shift. Which of the following clients should the nurse place priority on assessing first?
A client who had a myocardial infarction two days ago, and complains of soft stools after taking docusate sodium.
A client being treated for thrombotic thrombocytopenic purpura (TTP) who has had 120 mL of urine output in the last 12 hours.
A client who was admitted for premature atrial contractions (PACS) and whose most recent blood pressure is 148/89.
A client receiving furosemide for heart failure whose daily weight shows that he has lost 0.5 kg since yesterday.
The Correct Answer is B
A. While soft stools after taking docusate sodium is noteworthy, it is not immediately life-threatening and does not require urgent intervention.
B. Oliguria (low urine output) in a client with TTP is concerning because it may indicate acute kidney injury or worsening of the condition, requiring immediate assessment and intervention.
C. An elevated blood pressure in a client with PACs is important but not as critical as potential kidney dysfunction in the TTP patient.
D. A weight loss of 0.5 kg in a client with heart failure on furosemide may be expected and does not require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Vitamin K is an antidote for warfarin, not heparin.
B. Enoxaparin is a low molecular weight heparin and is contraindicated in patients with a history of HIT.
C. Warfarin is an oral anticoagulant used for long-term anticoagulation therapy and is not used to neutralize heparin.
D. Protamine sulfate is the specific antidote for heparin and is used to neutralize its effects.
Correct Answer is ["24"]
Explanation
To calculate the IV pump rate, you'll need to use the formula: (Ordered amount of medication (units/hr) × Volume of fluid in mL) / Amount of medication in the volume = IV pump rate in mL/hr. For the given scenario, the ordered amount is 1,200 units/hr, the volume of fluid is 500 mL, and the amount of medication in the volume is 25,000 units. Plugging these numbers into the formula gives you: (1,200 units/hr × 500 mL) / 25,000 units = 24 mL/hr. Therefore, the nurse should set the IV pump to deliver 24 mL/hr.
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