A patient presents with a heart rate of 130 beats/minute and a blood pressure of 82/66 after exerting themselves in the sun. Which of the following interventions would be most appropriate?
Administer a hypotonic solution
Administer a vasoconstrictor medication
Administer an isotonic solution intravenously
Administer a hypertonic solution intravenously
The Correct Answer is C
A. Administering a hypotonic solution would not be appropriate in this case. Hypotonic solutions can lower the blood pressure further and worsen the patient’s condition.
B. Administering a vasoconstrictor medication may increase blood pressure, but it is not the first-line treatment for dehydration or volume loss, which seems to be the cause of the patient’s symptoms.
C. Administering an isotonic solution intravenously is the most appropriate intervention. The patient is likely experiencing dehydration and hypotension due to fluid loss from exertion in the sun (possibly heat exhaustion). Isotonic fluids such as normal saline or lactated Ringer's solution are typically used to restore circulating volume and improve blood pressure.
D. Administering a hypertonic solution would be inappropriate, as it could increase the osmolarity of the blood and worsen dehydration, potentially causing fluid shifts that could lead to complications such as cellular dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Orthostatic hypotension can be concerning, but it is not as immediately alarming as a very elevated WBC count. It could indicate dehydration or blood loss, which are common in Crohn's disease exacerbations, but it is not as critical as an infection or severe inflammation.
B. A WBC count of 83 (normal range is typically 4,000-11,000) is significantly elevated and suggests a severe infection or inflammatory response, which is a critical concern in Crohn's disease exacerbations. This could indicate a life-threatening complication such as an abscess or perforation.
C. Lack of appetite for 2 days is common during an exacerbation of Crohn's disease, though it can contribute to dehydration or malnutrition, it is not as immediately concerning as an elevated WBC count.
D. Abdominal cramping is a typical symptom of Crohn's disease and may worsen during exacerbations, but it is not the most concerning finding compared to a severely elevated WBC count.
Correct Answer is B
Explanation
A. An area of non-blanchable redness on intact skin is characteristic of a stage I pressure injury, not stage II. In stage I, the skin remains intact but shows redness that does not blanch when pressed.
B. An area of shallow broken skin with blistering describes a stage II pressure injury. Stage II involves partial-thickness loss of skin, which may present as a blister or shallow open ulcer, often with a pink or red wound bed.
C. Deep purple discoloration over intact skin refers to a suspected deep tissue injury, which is a different classification of pressure injury. It indicates damage to underlying tissue but does not involve a break in the skin.
D. An open wound with visible adipose tissue and eschar is indicative of a stage III pressure injury, which involves full-thickness skin loss and may expose underlying structures like fat, but not bone or muscle (which would indicate stage IV). Stage III wounds may also have eschar or slough, but stage II wounds do not.
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