An older client is admitted to the intensive care unit unconscious after several days of vomiting and diarrhea.

Vital Signs

Heart Rate-beats/minute- 110 Respirations - breathes/minute- 28 Blood Pressure – mmHG- 80/60

Arterial blood gases (ABGs)

Ph- 7.34

PaCO2- 34 mmHg

HCO3- 20 mmol/L

pO2- 90 mmHg

Electrolytes Results

Sodium

130 mEq/L(mmol/L) Potassium

2.5 mEq/L (mmol/L) Chloride

95 mEq/L (mmol/L)

Reference Range:

Sodium [136 to 145 mEq/L (136 to 145 mmol/L)]

Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Chloride [98 to 106 mEq/L (98 to 106 mmol/L)]

PaCO2 [35 to 45 mm Hg]

HCO, [21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg)

The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. Which intervention should the nurse implement first? (Please scroll and view each tab's information in the client's medical record before selecting the answer.)

Initiate continuous dopamine infusion at 2 mcg/kg/minute.

Administer promethazine 25 mg slow intravenous (IV) push every 4 hours.

Begin potassium chloride 10 mEq over 1 hour per secondary infusion.

Give a bolus of 0.9% sodium chloride 1,000 ml over 30 minutes.

Answer and Explanation

The Correct Answer is D

A)   Incorrect - Initiating continuous dopamine infusion is not a priority in this situation. The client's low blood pressure and electrolyte imbalances require more immediate attention.
B)   Incorrect - Administering promethazine addresses symptoms like nausea and vomiting, but it doesn't address the primary issue of hypovolemia and low blood pressure.
C)   Incorrect - Administering potassium chloride without addressing the fluid deficit can be dangerous and may lead to further electrolyte imbalances.
D)   Correct- The client's vital signs and laboratory results indicate hypovolemia (low blood pressure, low sodium, and low potassium). The immediate priority is to address the fluid deficit and correct the electrolyte imbalances. Administering a bolus of 0.9% sodium chloride (normal saline) will help increase intravascular volume and improve blood pressure, as well as correct the electrolyte imbalances to some extent.

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Correct Answer is D

Explanation

A) This can be done if initial non-pharmacological interventions do not relieve symptoms, but it is not the first step.
B) Monitoring blood pressure is important, but it is secondary to removing the stimulus causing the dysreflexia.
C) Incorrect- While education is important for long-term management, the client is currently experiencing symptoms that need immediate attention. The priority is to assess and address the current symptoms.
D) The client is likely experiencing autonomic dysreflexia, characterized by a sudden and severe increase in blood pressure, flushing, headache, and other symptoms triggered by a noxious stimulus below the level of injury. The first step in managing autonomic dysreflexia is to identify and eliminate the triggering stimulus. For clients with a Foley catheter, a common cause of autonomic dysreflexia is bladder distention due to a kinked or obstructed catheter. Relieving any kinks or obstructions in the Foley tubing can immediately alleviate the symptoms.

A. Observe the color of urine. B. Assess skin turgor. C. Measure body temperature. D. Check for pedal edema.

Correct Answer is A

Explanation

To monitor for adverse effects from prasugrel, a platelet inhibitor, the nurse should prioritize assessing for bleeding or abnormal bleeding tendencies. Therefore, observing the color of urine is the most important assessment among the options provided.

Changes in urine color, such as the presence of blood or dark-colored urine, can indicate internal bleeding or bleeding in the urinary tract, which can be a potential adverse effect of platelet inhibitors. It is crucial to monitor for signs of bleeding to ensure the client's safety and intervene promptly if necessary.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

A client with a chlamydia infection receives a prescription for a single dose azithromycin 1 gram by mouth. The bottle is labeled "Azithromycin for Oral Suspension, USP 200 mg per 5 mL." How many mL should the nurse administer? (Enter numerical value only.)

A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (DW) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump?

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?

Patient Data What other treatments might be helpful for this client? Select all that apply.