Exhibit 1 Exhibit 2 Graphic Record Blood pressure 176/122 mm Hg Heart rate 136/min Respiratory rate 32/min Exhibit 3 O2 saturation 88%.

A nurse in the emergency department is caring for a client who was involved in an explosion.

Which of the following actions should the nurse plan to take first? (Click on the "Exhibit" button for additional information about the client.

Obtain an ECG.

Calculate the extent of burns using the rule of nines.

Notify the Rapid Response Team.

Initiate peripheral IV access.

Answer and Explanation

The Correct Answer is C

The nurse should plan to notify the Rapid Response Team first.
The client’s blood pressure is elevated, heart rate is high, respiratory rate is high, and oxygen saturation is low.
These are all signs of potential instability and the Rapid Response Team should be notified immediately.
Choice A is incorrect because while obtaining an ECG may be important, it is not the nurse’s first priority in this situation.
Choice B is incorrect because while calculating the extent of burns using the rule of nines may be important, it is not the nurse’s first priority in this situation.
Choice D is incorrect because while initiating peripheral IV access may be important, it is not the nurse’s first priority in this situation.

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Correct Answer is C

Explanation

“I’m too tired to brush my teeth.” This statement indicates that the client is experiencing fatigue, which is a common symptom of heart failure.
Fatigue can significantly impact a person’s ability to perform daily activities and can be an indication that the client needs a referral for cardiac rehabilitation 1.
Choice A is not the correct answer because weighing oneself daily is a recommended self-monitoring technique for clients with heart failure.
Choice B is not the correct answer because while feeling unhappy can be a symptom of heart failure, it does not necessarily indicate a need for cardiac rehabilitation.
Choice D is not the correct answer because eating a low-sodium diet is a recommended dietary change for clients with heart failure.

A. Sodium 136 mEq/L. B. Creatinine 0.8 mg/dL. C. Potassium.2 mEq/L. D. BUN 18 mg/dL.

Correct Answer is C

Explanation

Furosemide is a loop diuretic that can cause loss of potassium from the body.
A potassium level of.2 mEq/L is considered low (hypokalemia) and can be a contraindication for receiving the medication.
Sodium 136 mEq/L is within the normal range and is not a contraindication for receiving furosemide.
B) Creatinine 0.8 mg/dL is within the normal range and is not a contraindication for receiving furosemide.
D) BUN 18 mg/dL is within the normal range and is not a contraindication for receiving furosemide.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has heart failure. Which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation?

Correct Answer is C

Explanation

A nurse is preparing to administer furosemide to a client who has acute heart failure. Which of the following laboratory results should the nurse identify as a contraindication for receiving the medication?

Correct Answer is C

Explanation

A nurse is monitoring a client who is receiving 2 units of packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction?

A nurse is providing teaching to a client who has a deep-vein thrombosis (DVT). Which of the following findings should the nurse identify as a risk factor for developing DVTS?

A nurse is caring for a client who is experiencing a hypertensive crisis. Which of the following actions should the nurse take?

A nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?

A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take?

A nurse is caring for a client admitted with a skull fracture. Which of the following assessment findings should be of greatest concern to the nurse?

A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect?

A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?