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 D

Explanation

A.While pain management is important, it is not the most critical intervention compared to monitoring for bleeding, which can be life-threatening.

B.Teaching the client how to use incentive spirometry is important for improving lung function and preventing complications like atelectasis. However, in the context of a pulmonary embolism (PE), the immediate priority is to monitor for signs of increased bleeding due to the anticoagulant or thrombolytic therapy often used to treat PE. This is crucial to prevent potentially life-threatening complications.

C.Confusion and restlessness could indicate hypoxia, which is important to monitor in a PE patient. However, the immediate risk of bleeding due to anticoagulation therapy takes precedence.

D.Patients with a pulmonary embolism are typically treated with thrombolytic or anticoagulant therapy to prevent further clot formation and to help dissolve the existing clot. Anticoagulants significantly increase the risk of bleeding, making it crucial to monitor for signs of increased bleeding as a priority in the plan of care.

A. Dullness bilaterally on percussion. B. Serosanguinous drainage from the chest tube. C. Diminished breath sounds in the left lower lobe. D. Mediastinal shift to the right.

Correct Answer is D

Explanation

A) Incorrect- Dullness bilaterally on percussion is not a normal finding, but it is not an immediate concern after thoracentesis. It may indicate fluid accumulation or consolidation in both lungs, which could be related to other conditions such as pneumonia or heart failure.
B) Incorrect- Serosanguinous drainage from the chest tube is expected after thoracentesis, as long as it is not excessive or continuous. The nurse should monitor the amount and color of the drainage and document it accordingly.
C) Incorrect- Diminished breath sounds in the left lower lobe are also expected after thoracentesis, as the procedure removes fluid and air from the pleural space and reduces lung expansion. The nurse should auscultate the lungs before and after the procedure and compare the findings. The breath sounds should improve gradually as the lung re-expands.
D) Correct- This is a sign of tension pneumothorax, which is a life-threatening complication of thoracentesis. Tension pneumothorax occurs when air accumulates in the pleural space and creates positive pressure that pushes the mediastinum (the heart, great vessels, and trachea) to the opposite side of the chest. This can impair venous return, cardiac output, and respiratory function. The nurse should report this finding to the healthcare provider immediately and prepare to assist with needle decompression or chest tube insertion.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

Correct Answer is D

Explanation

The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

Correct Answer is D

Explanation

A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take? Reference Ranges Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Exhibits The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress?

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?