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.

Nursing Test Bank

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Correct Answer is A

Explanation

A.Tingling on the tongue or lips is an early sign of an allergic reaction to the contrast dye used during an intravenous pyelogram. This type of reaction can quickly progress to more severe symptoms, such as difficulty breathing and anaphylaxis, so it is crucial to recognize and respond to it promptly.

B. Episodes of shivering: Shivering is not typically an early sign of an allergic reaction to contrast dye. It might indicate a reaction to temperature or anxiety but is not as immediately concerning as symptoms of an allergic reaction.

C. Salty taste in the mouth: A salty or metallic taste is a common and benign side effect of the contrast dye and is not indicative of an adverse reaction.

D. Difficulty breathing: Difficulty breathing is a severe and later sign of an allergic reaction. By the time this symptom appears, the reaction has progressed and immediate intervention is necessary.

A. A salad with three kinds of lettuce and fruit. B. Vegetable soup, crackers, and milk. C. A peanut butter sandwich with soda and cookies. D. A tuna fish sandwich with chips and ice cream.

Correct Answer is D

Explanation

A) Incorrect - While a salad includes vegetables and fruits, it may not provide sufficient protein for wound healing.
B) Incorrect - Vegetable soup and crackers might not provide enough protein compared to other options.
C) Incorrect - While a peanut butter sandwich includes some protein, soda and cookies are not rich sources of protein.
D) Correct- A tuna fish sandwich is a good source of protein. Protein is essential for wound healing as it supports tissue repair and regeneration. The choice of a tuna fish sandwich along with chips and ice cream suggests a balanced meal with adequate protein content, which aligns with the teaching of a high protein diet to promote wound healing.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure?

Correct Answer is A

Explanation

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

Correct Answer is D

Explanation

An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement?

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The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?

When should the nurse conduct an Allen's test?

The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply.)

When providing community healthcare teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (Select all that apply)?

Exhibits here What should the nurse include in pre-discharge education for this child's parents? Select all that apply.

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