A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

Administer an anticholinesterase medication.

Instruct the client to perform the pursed lip breathing.

Prepare to administer a vasoconstrictor.

Prepare the client for mechanical ventilation.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Administering an anticholinesterase medication is not the primary intervention during a myasthenic crisis. While these medications can improve muscle strength in myasthenia gravis, they are not sufficient in the event of a crisis.

Choice B reason:

Pursed lip breathing is a technique used to manage dyspnea but is not adequate for the acute management of a myasthenic crisis, which can involve respiratory muscle paralysis.

Choice C reason:

Vasoconstrictors are not used in the treatment of myasthenic crisis. This condition is not related to vascular issues but to neuromuscular transmission failure leading to respiratory failure.

Choice D reason:

Mechanical ventilation is the correct intervention as it provides the necessary respiratory support when the patient's respiratory muscles are too weak to maintain adequate ventilation.

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Correct Answer is A

Explanation

The nurse should instruct the client to adjust the thermostat so that the environment is warm because cold temperatures can cause vasoconstriction and worsen the symptoms of PAD, such as pain, numbness, and poor wound healing. The client should also avoid exposure to cold weather and wear warm clothing.

Apply a heating pad on a low setting to help relieve leg pain is wrong because it can cause burns, vasodilation, and increased blood ﬂow to the legs, which can increase the risk of bleeding and edema in PAD.
Wear antiembolic stockings during the day is wrong because they can impair arterial circulation and cause ischemia and tissue damage in PAD. Antiembolic stockings are used to prevent venous thromboembolism, not arterial disease.

Rest with the legs above heart level is wrong because it can decrease arterial blood ﬂow to the legs and worsen ischemia and pain in PAD. The client should rest with the legs at or below heart level to promote arterial circulation.

Correct Answer is ["24"]

Explanation

To calculate the infusion rate, use the formula:

(rate in mL/hr) = (desired dose in units/hr) / (available dose in units/mL)

In this case, the desired dose is 1,200 units/hr and the available dose is 25,000 units / 500 mL = 50 units/mL. Therefore,

(rate in mL/hr) = (1,200 units/hr) / (50 units/mL) = 24 mL/hr

Round the answer to the nearest tenth/whole number and use a leading zero if it applies. Do not use a trailing zero because it could be misread as a decimal point. Therefore, the nurse should set the IV pump to deliver 24 mL/hr.

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A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

Correct Answer is ["24"]

Explanation

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