Complete the following sentence by using the list of options.
The nurse should first anticipate the need to
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale:
• Obtain IV access is the first priority because the client is showing signs of hypovolemic shock low blood pressure (76/45 mm Hg), tachycardia (HR 121/min), pale mucous membranes, and diaphoresis likely due to GI bleeding. Immediate vascular access is necessary for resuscitation and fluid administration.
• Call the surgical suite to notify that the client is arriving STAT would delay essential stabilization. Transporting an unstable client without securing IV access and fluid resuscitation could worsen their condition and is unsafe.
• Place the client in a supine position with feet elevated (modified Trendelenburg) might temporarily improve venous return, but it does not address the underlying fluid deficit. It is not a substitute for urgent fluid replacement via IV access.
• Recheck the client's oxygen saturation is not a priority because the client already has a stable oxygen saturation of 98% on room air. The immediate threat is circulatory collapse, not hypoxia.
• Prepare to administer IV fluids follows IV access to treat hypotension and restore circulating volume. IV fluids help stabilize hemodynamics while awaiting further interventions like endoscopy or blood transfusion if needed.
• Transport the client for endoscopy is inappropriate at this moment because the client is hemodynamically unstable. Endoscopy is important but must be delayed until the client is stabilized.
• Check the ECG may be useful if cardiac concerns arise due to hypotension or tachycardia, but it does not take precedence over immediate circulatory support in this scenario.
• Check arterial blood gases would not provide data that immediately changes the management. The client's O2 saturation is normal, and ABGs are not needed to diagnose or treat hypovolemic shock due to GI bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Explanation
Rationale:
• Compartment syndrome: Casts can restrict swelling, increasing pressure within the compartment. Moderate toe edema and capillary refill slowing from brisk to 3 seconds are warning signs. Without prompt intervention, tissue perfusion may decline, leading to ischemia.
• Edema of toes: Progressive edema signals impaired venous return or rising intracompartmental pressure. It reflects worsening limb status under the cast. This change, with slowed refill, supports risk for compartment syndrome.
• Malunion: Malunion develops over weeks due to misalignment during healing. No imaging or prolonged healing time is reported. Acute symptoms like swelling and pain don’t indicate this long-term issue.
• Physeal damage: Growth plate injury would affect long-term limb development. The adolescent shows intact toe movement and normal limb function otherwise. No evidence of joint or bone disruption is presented.
• Inability to ambulate: The femur fracture and cast already restrict ambulation. Lack of walking is expected at this stage. It doesn't suggest any specific complication like infection or compartment syndrome.
• Infection: Fever is low-grade and expected post-injury or from opioids. No redness, drainage, or systemic illness is present. Pain is stable and localized, not escalating or spreading.
• Decreased dorsalis pedis pulse: Pulses are 2+, meaning circulation is present and adequate. Decreased or absent pulse would indicate severe compromise, but that is not seen here. It does not reflect early compartment syndrome.
Correct Answer is C
Explanation
Rationale:
A. Removing an NG tube: Removing a nasogastric tube is a task that can be safely delegated to a licensed practical nurse (LPN) under appropriate supervision, as it is considered a stable, routine procedure that does not require complex assessment.
B. Administering a subcutaneous insulin injection: LPNs are trained and authorized to administer subcutaneous injections, including insulin, as long as the client's condition is stable and the dose is clearly prescribed.
C. Providing discharge teaching about home IV medication therapy: Discharge education involving IV therapy requires comprehensive teaching, clinical judgment, and evaluation of understanding, which falls within the scope of practice of a registered nurse (RN).
D. Collecting a sputum culture: Collecting a sputum specimen is a basic nursing task that can be performed by an LPN or even by trained assistive personnel, depending on facility policy. It does not require the expertise of an RN.
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